On The Contradictions Around Facial Feminization Surgery
I've tiptoed around this one for a while. It's a tough one because a lot of the shame issues wrapped up in this issue are exactly my issues. It's a bit self-absorbed, but my feeling is that if I am personally hesitant to engage an issue in a public forum, it's a really important one to force, because it is my tendency to put myself out there to a fault. If I'm scared to touch it, I just think about the other people who aren't attention whores who might need folks to speak up. Hi. I'm gonna try. I hope I manage to say something that's a little understandable.
Facial Feminization Surgery (FFS) is an issue that brings up a LOT of stuff. It's wrapped up in priveledge, transphobia, dysphoria, and body shaming from several sides. FFS is a set of reconstructive facial surgery procedures that alter typically male facial features to bring them closer in shape and size to typical female facial features. It's plastic surgery. That's what it is. Plastic surgery is SUCH a hot button all by itself, that trans folks looking to have FFS are in a bit of a public opinion pickle right out of the gate. I've had some pretty amazing experiences with shaming and strong opinions that I'll try to relate, but let's look at the whys and hows in a more general sense.
Puberty is a mean bitch when it comes to gender variant folks. Your endocrine system gets all uppity and starts doing its programmed job, producing and shipping hormones all over the place. As time passes, your body changes a lot. Bone structure, size, all manner of nonsense starts happening. You grow facial hair or you sprout boobs. Your muscle mass increases or your hips widen. A lot of people don't realize, though, how ectensive this process is. There are a zillion and one little and big changes, including the development of many 'Secondary Sex Characteristics' (SSC).
You get no say in this process. If your body is pumping out the wrong hormones, you get the changes. Sorry Poopsie. You cannot unwiden hips, but FFS can address SOME changes. Men develop something called brow bossing. A bony ridge develops above the eyes creating a very masculine appearance. In extreme circumstances, think caveman.
Male noses are both wider and bigger than female noses. Male jaws are both wider and more angular, cheekbones are less prominent. Interestingly, the distance between the upper lip and the nose is significantly greater in men than in women. The male hairline begins farther up the forehead than the famale hairline and is also more square in shape. One of the most discussed SSCs is the adams apple. Ladies, you have one too. As the male voice changes, the larynx shifts to make some room, resulting in more prominence. Obviously, these are generalities - there are women with traditionally masculine features and there are men with generally feminine features, but on the balance, these are the rules, and these are the visual cues we use to determine gender - it's hardwired. No amount of societal change is gonna fix it.
For trans people, SSCs are literally malformations. It's not an analogy. Mismatched SSCs are a very real medical defect. Medical and mental health science overwhelmingly agree. If something is physically wrong with a person to the point that it is causing physical distress, and the technology exists to FIX them, it is both medically and ethically necessary that this happen. The World Professional Association for Transgender Health (WPATH) is generally recognized as the authority on transgender standards of care, and they are very clear on this. The AMA, the APA, and about five zillion other medical and mental health professional organizations follow their lead. FFS is medically necessary corrective surgery for many, many transgender people. Man. this issue has so many tendrils. I am really trying here, I swear. It's hard as hell to be organized on this. Do we need a little more 'WHY' before moving on to 'HOW' and 'OH FUCK'? I think we need more 'WHY.'
The development of SSCs can be really, really distressing in its own right, but the damn things play a HUGE role psychosocially. Huge. Visual gender recognition is a cognitive skill that is automatic, almost instant, and developed when you are a baby, and SSCs are the primary mechanism, here. Babies learn to differentiate male and female by looking at faces. They don't look at makeup, nails, clothing, or hair. They look at faces. You still do that now. It's instant. Sure, as an adult, you then take in context, but the mental work is done and you have sorted the person in front of you into the gender binary - that's a boy, this is a girl. For many, that then shapes the interaction moving forward. In a safe space, with friends or allies, this is no big deal. In public, it can literally mean life or death, and certainly opens you up to all manner of unpleasant interactions. Every day. Think about that. Every single day.
Can I give you an example? There are things you can do to cover or disguise SSCs. Wigs and hats obscure brow bossing. Makeup can do quite a bit when you learn about contouring. You can cover even a really dark beard shadow if you know how - ask RuPaul. Dude has a majestic beard when he wants. When you go to the store or out to run a few simple errands, you might be willing to throw on some sweatpants and just dash out. Sure, you're not looking great, but you're just getting some milk and returning a library book, right? Many trans people can't do that. I can't. There's a whole huge decision to be made when we need milk. Do I want to deal with the funny looks? Do I want to get misgendered? Am I in a good mental place for that? If not, there goes at least half an hour of covering up SSCs.Even here in my lovely little town, I know that there are times I can go to the store without worrying about it, and there are times when I'm gonna at the very least get the hairy eyeball. It wears on you over time and it can be really, really painful. Many places are far worse, with outright aggression. I'm fortunate.
There's a really, really important point here that CAN NOT be overstated. This is NOT NOT NOT the same thing as the girl you know who insists on being perfectly made up before she leaves the house. She likes to look nice. Sure, maybe she does have some self image issues and that sucks, but a trans person does it to avoid being discriminated againt. To assure that we can pee while we are out if we need to. We do it so that we can take our kids to a playgroup without being treated as a pariah, and so that our kid will hopefully get to play with other kids. We do it so that people do not kill us. I recently had a very strong ally react VERY poorly to my pursuit of FFS. She told me that "No woman likes to go out without makeup." No, bitch. First of all, many do, and I tend to hang with them. Second, THIS IS NOT VANITY AND YOU DON'T UNDERSTAND YET! The same woman then told me that I "really look like a woman already." Thanks. I really am a woman already. A woman with some medical defects that I'm trying to address. A really strong ally with a LOT of exposure to trans women. Can you imagine the opinions of the general public, here? So try to read my drivel, okay - it will help you. SSC bypasses an UNCHANGEABLE developomental recognition system in the human brain.
I have dear, dear friends and a lovely, supportive wife who love my face. I love their faces, too. I love every crease and groove and dimple. Faces are people to many of us. Changing faces at all is symbolically changing the visual center of a person in our minds and hearts. It feels a little bit like loss on a mental level. There's a ton of fear tied to loss, and so we react. It happens. To add to it, these lovely people already see me as a woman every day. They're on board with my identity, and they know me well, so it's all good. I love it and am SOOO grateful. Once you see me as me, it can be really easy to bypass SSCs. I'm familiar. I'm one of your tribe. Your brain doesn't need to sort me. I'm already sorted for you, so your gender recognition system takes a break. I see a lot more strangers every day than I do bosom pals, and their gender recognition systems are on high alert, I promise.
Another argument? "So WHAT?! Screw them if they can't accept you!" This is super punk rock and I love it, but it's not realistic for most. I'm not sure it's realistic for anyone, in fact. I'm not gonna belabor the things that make this true. Violence, arrest, abuse, access, employment... that stuff. Pretty big 'WHY' right there.
Next? VANITY. Oh my GOD do I hate the vanity argument. I am absolutely vain. I am. I'm a freaking selfie MACHINE sometimes. I think I'm kinda cute sometimes. I think I'm kinda smart sometimes. I am pretty damn handy, if I do say so. I can sing to bring the house down. I have a SOLID degree of vanity. This isn't that. This is getting a cleft lip repaired. It's having a dislocated shoulder set. FFS is fixing what's broken. Nobody assumes that somebody getting other corrective surgeries are doing it to be pretty. If I am successful in getting my FFS, I am not doing it to be pretty. I picked my surgeon, in fact, because he does not attempt to crank out "sexy." He is known for making recognizable and natural faces - versions of people similar to how they would have looked if they hadn't been fed a load of hormonal horseshit by their bodies. Will I complain if it turns out I'm a knockout? Fuck no. But for crying out loud... vanity. I'm WAY WAY too awesome for that.
Surely I've missed some of the WHY - and the why is really, really huge. The WHY is what people need to get their heads around before change can happen with the rest, because so long as people are able to view FFS as elective, cosmetic, vain, superfluous, or otherwise morally or culturally repugnant, they will not be able to entertain issues of access, priveledge, and support. These are the things I want to talk about next.
I'm very fortunate to be super privileged. I'm white. I have really excellent health insurance. I'm well-educated and both knowledgeable and experienced enough to be able to fight some pretty epic battles on my own behalf. Even in my case, though, things are really tough with regards to access to FFS. It's expensive! Depending on the surgeon, the procedures needed, and WHERE the surgery is done, FFS will cost between $10,000 and $60,000. Many US trans women travel out of the country to have it done, where it is cheaper. That's actually generally quite safe, but a huge pain. Even so, though, the cost of FFS makes it completely innaccessible to the VAST MAJORITY of trans women (who are far more likely than the general populace to be unemployed or to live in poverty). The class divide is very broad, here. Me, though, I have great insurance! I should have no problem with this medically necessary procedure, right? Not so fast. Check this out:
Only 18 states currently have laws specifically protecting trans people. In the other states, that means we can be fired, evicted, denied service and excluded from medical insurance policies completely. So that kinda sucks a little. Even just in the job thing, 26% of trans people HAVE INDEED been fired for their gender identity - it's not just a conceptual danger. It's happening every day and I'm talking to the men and women who go through it. It's horrible. Loss of income leads to loss of housing leads to loss of services leads to... danger danger danger. 41% of us have actively attempted suicide. MOST of us report occasional suicidality. 78% of us report direct physical or sexual violence. 69% have been or are homeless. 57% report family estrangement, so when the shit hits the fan, they have nowhere to turn. 60% of trans people HAVE BEEN OUTRIGHT REFUSED MEDICAL CARE BY PROVIDERS. We're a very highly uninsured population, even post Obamacare, 19% of trans people report having no form of medical coverage at all, including Medicaid. This isn't a tangent... well maybe it is, but it directly addresses some of the issues around FFS here. In 32 states, insurance companies AND Medicaid/Medicare can just wholesale exclude transgender-related coverage. Sure, that includes FFS, but also hormones and hormone supervision AND care that does not conform with legal gender, so a pregnant trans man (who HAS jumped through the hoops of correcting his legal gender) could be denied care. A trans woman who has NOT changed her legal gender could be denied breast cancer screenings, but if she HAS changed her legal status she could lose access to prostate screenings. Lose/lose.
For me? I'm gonna pull in my narrative again both because I'm really vain (remember?), but also because it is really illustrative of how even in what ought to be ideal situations with privilege and skill AND the law on your side, transgender health care is not remotely a sure thing. I'm not out of the woods. I'm in Vermont - it's one of the states that has specifically outlawed a whole bevy of trans descriminations, and that includes denials of medical care for transgender services. What happens next in these states is an attempt to define transgender related coverage. In nearly every state so far that has legally required trans care, insurance companies have specifically excluded FFS from the covered services, identifying it as elective, cosmetic, and not medically necessary (Massechussetts, I've heard, specifically prohibits this sort of exclusion, though my Boston-based surgeon tells me they still routinely deny claims). Almost every state and insurance company repeatedly quote WPATH standards of care as authorotative when discussing trans care, yet they disregard this point in a big way. My excellent insurance would slap a vagina on me quicker than a teenage boy can finish if I asked them to, but no FFS. So... game over? One might think so, but I'm kinda persistent. I mean... that's not the word people use, but that's what they're saying.
I found the exclusions in my policy and I found the law requiring insurers to cover all medically necessary transgender care. I found like... a dozen major medical and mental health organizations calling FFS medically necessary. I found DOZENS of published, peer-reviewed studies backing these organizations' statements up. I called the commissioner of the state regulatory agency in charge of medical coverage (Vermont is cool like that because you can get these people on the phone). I wrote empassioned letters until I found a lawyer willing to advise and represent me pro bono through the process. I put together a request for services that was so covered in citations that they took up more space on the page than the actual letter itself. I got clear letters from two medical professionals and a mental health professional declaring unequivicably that this procedure is a medical necessity for me. This took MONTHS of work, research, access to the internet, knowedge of how to find what I needed, about 50 phone calls, 4 doctor visits, a really good relationship with my therapist, a lot of luck, and a fucking partridge in a pear tree. A trans woman in poverty, without an education, without access to resources, without a doctor or a therapist, without a phone? The law is the same for us both, but she would not have a PRAYER. Access is a serious problem. And this is in a state where there are trans protections that specifically apply!
Have I been successful? With all of this artillery, I'm all set, right? Not yet. The insurance company came back to me with a few specific forms that needed filling out. They asked for a lot of information that was tough to track down, as well as a consultation with the surgeon. That took me almost 6 weeks to collect, schedule, communicate about, organize, and get submitted. Technically they need to get back to me soon, but the expectation is the they will deny my surgery. This forces me to appeal. Once I do, they deny me again, and I need to appeal again. The scenario becomes increasingly insane as it goes on. Each time I appeal, they can ask for clarification or data, which I then need to track down and get to them. Months and months pass in this back and forth. The third appeal happens outside of the insurance company, at a state insurance board that specifically hears these appeals. I would EXPECT that at this point, the board would find in my favor and force the insurance company to cover my procedures, but it's certainly possible that they won't, at which point we move on into the court system and I sue for coverage, where similar cases indicate that I would win. My feeling is that it's in the insurance company's best interest to just cover the FFS before then, because a lawsuit gets a LOT of attention AND sets precident, making future denials for others nearly impossible. The appeals process is SO intense, I imagine it's enough to discourage most people from even trying, so the insurers have a clear interest in keeping it intact. Regardless... next week or in three years, I will win and I will proceed, but it's absurd that you practically need to earn a PhD in this stuff in order to get medically necessary care in a liberal state.
I know I know I know that this is getting tiresome, but I need to continue my scenario for you because it's jaw-droppingly silly. The process is just absurd. Let's go. I win. I mean, I'm GONNA win at some point. I don't stop coming for you 'til we're both crying and I get what I want. Time for my surgery, right? Nope. FFS is a very specialized procedure. There are about 8 doctors in the world doing this well, and there are about 5 who do it really really well. Guess how many of these doctors are in my insurance network? If you guessed NONE, you are correct! The terms of my insurance do not REQUIRE me to see an in-network provider, but they DO make me pay as much as 70% of the total cost out of pocket if I choose to see someone out of network. There are actually really good reasons for this - insurers have agreements with in-network providers that keep costs down and limit what they can charge for procedures. Insurers funnel members toward in-network doctors, giving them more patients. Patients have a clear list of specialists to turn to that are known to meet the standards of the insurer. It's an alright system for what it is. For me, though, it's no good. FFS specialists are so incredibly rare that MOST insurance networks will not contain one, and even if they do, they may not excel at the work... not good when your face is being mucked about with.
So what next? Likely the insurance company sends me to their in-network plastics person to have a chat and discuss the procedure. This goes one of two ways. If the doctor is a reasonable, grounded, self-aware person, they take a look at the situation and recognize it as absurd. "I have no experience in doing work with the intent of sculpting new SSCs! I cannot help you! You must see Dr. XYZ, that out of network surgeon you've already spoken with!" they exclaim, and they tell the insurance company as much. We're dealing with plastics people here. though. They are notoriously NOT reasonable, grounded, and self-aware. They tend toward ego and tend not to be SUPER risk-averse when compared with some other specialties. The worst possible outcome for me is that the in-network plastic surgeon declares the procedure to be within their established skillsets. I'm not sure what would happen then, but I imagine it would be a horrible additional set of appeals and arguments. Once I DO get the insurance company to admit that they have no specialist capable of the job in-network, they are required to cover an out-of-network specialist identically to an in-network specialist. The law specifies some distance guidelines that require a specialist that is as close as possible to the patient's home, so the guy I picked to consult with is the closest there is (actually, the guy in Montreal might be a little closer, but leaving the country isn't gonna work). In theory this is the point where we can book the surgery.
I have absolutely NO DOUBT that there will be bumps here that I have not anticipated here, but that's the process that I have started. I'm not sure how to better demonstrate the insanity of attempting to access transgender care than by showing you what I know of my process.
Whoah, whoah, whoah, Rachel. Back things up, here. Maybe we've been able to demonstrate necessity, and sure, equal access to healthcare is a great thing, but you already demonstrated that this stuff is wicked expensive! Wouldn't increases in trans coverage increase healthcare costs? Why should other members subsidize your surgeries? Well. Most importantly, that's kinda how health insurance works. We subsidize your medically necessary pacemakers, and you occasionally subsidize the construction of a new cock, but that's simplistic. Fortunately, the issue has been studied to death. Across even relatively small companies, the cost increases for adding comprehensive transgender coverage to policies has been shown to be so small that it's not measureable. Yup - several studies on it found ZERO overall increase. That's in total cost, not in your premiums. With these pricey procedures, how could the POSSIBLY be? A big part of it is that there are so few of us. The best estimates out there right now peg transgender folks at less than 0.3 percent of the US population, somewhere in the realm of one quarter of one percent. So we're rare critters. That means that there will be a very small percentage of people taking advantage of the coverage. Not every transgender person pursues every available procedure, either. Some won't need FFS, others might not have genital reconstruction. Some of us don't even do hormone replacement therapy. Transgender coverage also tends to be a lot of one-time costs - they don't recur. Once you've had FFS, DING!, you are cooked. The hormones aren't gonna come and change things back. The result is, even providing completely unprecedented transgender coverage to every person with medical coverage in the entire nation would increase total healthcare costs by... not a measurable dollar given margins for error.
Transition is a LONG process, and it is different for each person who undergoes it. It takes years of effort and many, many decisions. My transition will not look exactly like any other out there. This part - FFS - is something that tends to be swept under the rug, and that's a shame, because it needs to be understood in order to be accepted. Hopefully this is a step in that direction.
Facial Feminization Surgery (FFS) is an issue that brings up a LOT of stuff. It's wrapped up in priveledge, transphobia, dysphoria, and body shaming from several sides. FFS is a set of reconstructive facial surgery procedures that alter typically male facial features to bring them closer in shape and size to typical female facial features. It's plastic surgery. That's what it is. Plastic surgery is SUCH a hot button all by itself, that trans folks looking to have FFS are in a bit of a public opinion pickle right out of the gate. I've had some pretty amazing experiences with shaming and strong opinions that I'll try to relate, but let's look at the whys and hows in a more general sense.
Puberty is a mean bitch when it comes to gender variant folks. Your endocrine system gets all uppity and starts doing its programmed job, producing and shipping hormones all over the place. As time passes, your body changes a lot. Bone structure, size, all manner of nonsense starts happening. You grow facial hair or you sprout boobs. Your muscle mass increases or your hips widen. A lot of people don't realize, though, how ectensive this process is. There are a zillion and one little and big changes, including the development of many 'Secondary Sex Characteristics' (SSC).
You get no say in this process. If your body is pumping out the wrong hormones, you get the changes. Sorry Poopsie. You cannot unwiden hips, but FFS can address SOME changes. Men develop something called brow bossing. A bony ridge develops above the eyes creating a very masculine appearance. In extreme circumstances, think caveman.
Male noses are both wider and bigger than female noses. Male jaws are both wider and more angular, cheekbones are less prominent. Interestingly, the distance between the upper lip and the nose is significantly greater in men than in women. The male hairline begins farther up the forehead than the famale hairline and is also more square in shape. One of the most discussed SSCs is the adams apple. Ladies, you have one too. As the male voice changes, the larynx shifts to make some room, resulting in more prominence. Obviously, these are generalities - there are women with traditionally masculine features and there are men with generally feminine features, but on the balance, these are the rules, and these are the visual cues we use to determine gender - it's hardwired. No amount of societal change is gonna fix it.
For trans people, SSCs are literally malformations. It's not an analogy. Mismatched SSCs are a very real medical defect. Medical and mental health science overwhelmingly agree. If something is physically wrong with a person to the point that it is causing physical distress, and the technology exists to FIX them, it is both medically and ethically necessary that this happen. The World Professional Association for Transgender Health (WPATH) is generally recognized as the authority on transgender standards of care, and they are very clear on this. The AMA, the APA, and about five zillion other medical and mental health professional organizations follow their lead. FFS is medically necessary corrective surgery for many, many transgender people. Man. this issue has so many tendrils. I am really trying here, I swear. It's hard as hell to be organized on this. Do we need a little more 'WHY' before moving on to 'HOW' and 'OH FUCK'? I think we need more 'WHY.'
The development of SSCs can be really, really distressing in its own right, but the damn things play a HUGE role psychosocially. Huge. Visual gender recognition is a cognitive skill that is automatic, almost instant, and developed when you are a baby, and SSCs are the primary mechanism, here. Babies learn to differentiate male and female by looking at faces. They don't look at makeup, nails, clothing, or hair. They look at faces. You still do that now. It's instant. Sure, as an adult, you then take in context, but the mental work is done and you have sorted the person in front of you into the gender binary - that's a boy, this is a girl. For many, that then shapes the interaction moving forward. In a safe space, with friends or allies, this is no big deal. In public, it can literally mean life or death, and certainly opens you up to all manner of unpleasant interactions. Every day. Think about that. Every single day.
Can I give you an example? There are things you can do to cover or disguise SSCs. Wigs and hats obscure brow bossing. Makeup can do quite a bit when you learn about contouring. You can cover even a really dark beard shadow if you know how - ask RuPaul. Dude has a majestic beard when he wants. When you go to the store or out to run a few simple errands, you might be willing to throw on some sweatpants and just dash out. Sure, you're not looking great, but you're just getting some milk and returning a library book, right? Many trans people can't do that. I can't. There's a whole huge decision to be made when we need milk. Do I want to deal with the funny looks? Do I want to get misgendered? Am I in a good mental place for that? If not, there goes at least half an hour of covering up SSCs.Even here in my lovely little town, I know that there are times I can go to the store without worrying about it, and there are times when I'm gonna at the very least get the hairy eyeball. It wears on you over time and it can be really, really painful. Many places are far worse, with outright aggression. I'm fortunate.
There's a really, really important point here that CAN NOT be overstated. This is NOT NOT NOT the same thing as the girl you know who insists on being perfectly made up before she leaves the house. She likes to look nice. Sure, maybe she does have some self image issues and that sucks, but a trans person does it to avoid being discriminated againt. To assure that we can pee while we are out if we need to. We do it so that we can take our kids to a playgroup without being treated as a pariah, and so that our kid will hopefully get to play with other kids. We do it so that people do not kill us. I recently had a very strong ally react VERY poorly to my pursuit of FFS. She told me that "No woman likes to go out without makeup." No, bitch. First of all, many do, and I tend to hang with them. Second, THIS IS NOT VANITY AND YOU DON'T UNDERSTAND YET! The same woman then told me that I "really look like a woman already." Thanks. I really am a woman already. A woman with some medical defects that I'm trying to address. A really strong ally with a LOT of exposure to trans women. Can you imagine the opinions of the general public, here? So try to read my drivel, okay - it will help you. SSC bypasses an UNCHANGEABLE developomental recognition system in the human brain.
I have dear, dear friends and a lovely, supportive wife who love my face. I love their faces, too. I love every crease and groove and dimple. Faces are people to many of us. Changing faces at all is symbolically changing the visual center of a person in our minds and hearts. It feels a little bit like loss on a mental level. There's a ton of fear tied to loss, and so we react. It happens. To add to it, these lovely people already see me as a woman every day. They're on board with my identity, and they know me well, so it's all good. I love it and am SOOO grateful. Once you see me as me, it can be really easy to bypass SSCs. I'm familiar. I'm one of your tribe. Your brain doesn't need to sort me. I'm already sorted for you, so your gender recognition system takes a break. I see a lot more strangers every day than I do bosom pals, and their gender recognition systems are on high alert, I promise.
Another argument? "So WHAT?! Screw them if they can't accept you!" This is super punk rock and I love it, but it's not realistic for most. I'm not sure it's realistic for anyone, in fact. I'm not gonna belabor the things that make this true. Violence, arrest, abuse, access, employment... that stuff. Pretty big 'WHY' right there.
Next? VANITY. Oh my GOD do I hate the vanity argument. I am absolutely vain. I am. I'm a freaking selfie MACHINE sometimes. I think I'm kinda cute sometimes. I think I'm kinda smart sometimes. I am pretty damn handy, if I do say so. I can sing to bring the house down. I have a SOLID degree of vanity. This isn't that. This is getting a cleft lip repaired. It's having a dislocated shoulder set. FFS is fixing what's broken. Nobody assumes that somebody getting other corrective surgeries are doing it to be pretty. If I am successful in getting my FFS, I am not doing it to be pretty. I picked my surgeon, in fact, because he does not attempt to crank out "sexy." He is known for making recognizable and natural faces - versions of people similar to how they would have looked if they hadn't been fed a load of hormonal horseshit by their bodies. Will I complain if it turns out I'm a knockout? Fuck no. But for crying out loud... vanity. I'm WAY WAY too awesome for that.
Surely I've missed some of the WHY - and the why is really, really huge. The WHY is what people need to get their heads around before change can happen with the rest, because so long as people are able to view FFS as elective, cosmetic, vain, superfluous, or otherwise morally or culturally repugnant, they will not be able to entertain issues of access, priveledge, and support. These are the things I want to talk about next.
I'm very fortunate to be super privileged. I'm white. I have really excellent health insurance. I'm well-educated and both knowledgeable and experienced enough to be able to fight some pretty epic battles on my own behalf. Even in my case, though, things are really tough with regards to access to FFS. It's expensive! Depending on the surgeon, the procedures needed, and WHERE the surgery is done, FFS will cost between $10,000 and $60,000. Many US trans women travel out of the country to have it done, where it is cheaper. That's actually generally quite safe, but a huge pain. Even so, though, the cost of FFS makes it completely innaccessible to the VAST MAJORITY of trans women (who are far more likely than the general populace to be unemployed or to live in poverty). The class divide is very broad, here. Me, though, I have great insurance! I should have no problem with this medically necessary procedure, right? Not so fast. Check this out:
Only 18 states currently have laws specifically protecting trans people. In the other states, that means we can be fired, evicted, denied service and excluded from medical insurance policies completely. So that kinda sucks a little. Even just in the job thing, 26% of trans people HAVE INDEED been fired for their gender identity - it's not just a conceptual danger. It's happening every day and I'm talking to the men and women who go through it. It's horrible. Loss of income leads to loss of housing leads to loss of services leads to... danger danger danger. 41% of us have actively attempted suicide. MOST of us report occasional suicidality. 78% of us report direct physical or sexual violence. 69% have been or are homeless. 57% report family estrangement, so when the shit hits the fan, they have nowhere to turn. 60% of trans people HAVE BEEN OUTRIGHT REFUSED MEDICAL CARE BY PROVIDERS. We're a very highly uninsured population, even post Obamacare, 19% of trans people report having no form of medical coverage at all, including Medicaid. This isn't a tangent... well maybe it is, but it directly addresses some of the issues around FFS here. In 32 states, insurance companies AND Medicaid/Medicare can just wholesale exclude transgender-related coverage. Sure, that includes FFS, but also hormones and hormone supervision AND care that does not conform with legal gender, so a pregnant trans man (who HAS jumped through the hoops of correcting his legal gender) could be denied care. A trans woman who has NOT changed her legal gender could be denied breast cancer screenings, but if she HAS changed her legal status she could lose access to prostate screenings. Lose/lose.
For me? I'm gonna pull in my narrative again both because I'm really vain (remember?), but also because it is really illustrative of how even in what ought to be ideal situations with privilege and skill AND the law on your side, transgender health care is not remotely a sure thing. I'm not out of the woods. I'm in Vermont - it's one of the states that has specifically outlawed a whole bevy of trans descriminations, and that includes denials of medical care for transgender services. What happens next in these states is an attempt to define transgender related coverage. In nearly every state so far that has legally required trans care, insurance companies have specifically excluded FFS from the covered services, identifying it as elective, cosmetic, and not medically necessary (Massechussetts, I've heard, specifically prohibits this sort of exclusion, though my Boston-based surgeon tells me they still routinely deny claims). Almost every state and insurance company repeatedly quote WPATH standards of care as authorotative when discussing trans care, yet they disregard this point in a big way. My excellent insurance would slap a vagina on me quicker than a teenage boy can finish if I asked them to, but no FFS. So... game over? One might think so, but I'm kinda persistent. I mean... that's not the word people use, but that's what they're saying.
I found the exclusions in my policy and I found the law requiring insurers to cover all medically necessary transgender care. I found like... a dozen major medical and mental health organizations calling FFS medically necessary. I found DOZENS of published, peer-reviewed studies backing these organizations' statements up. I called the commissioner of the state regulatory agency in charge of medical coverage (Vermont is cool like that because you can get these people on the phone). I wrote empassioned letters until I found a lawyer willing to advise and represent me pro bono through the process. I put together a request for services that was so covered in citations that they took up more space on the page than the actual letter itself. I got clear letters from two medical professionals and a mental health professional declaring unequivicably that this procedure is a medical necessity for me. This took MONTHS of work, research, access to the internet, knowedge of how to find what I needed, about 50 phone calls, 4 doctor visits, a really good relationship with my therapist, a lot of luck, and a fucking partridge in a pear tree. A trans woman in poverty, without an education, without access to resources, without a doctor or a therapist, without a phone? The law is the same for us both, but she would not have a PRAYER. Access is a serious problem. And this is in a state where there are trans protections that specifically apply!
Have I been successful? With all of this artillery, I'm all set, right? Not yet. The insurance company came back to me with a few specific forms that needed filling out. They asked for a lot of information that was tough to track down, as well as a consultation with the surgeon. That took me almost 6 weeks to collect, schedule, communicate about, organize, and get submitted. Technically they need to get back to me soon, but the expectation is the they will deny my surgery. This forces me to appeal. Once I do, they deny me again, and I need to appeal again. The scenario becomes increasingly insane as it goes on. Each time I appeal, they can ask for clarification or data, which I then need to track down and get to them. Months and months pass in this back and forth. The third appeal happens outside of the insurance company, at a state insurance board that specifically hears these appeals. I would EXPECT that at this point, the board would find in my favor and force the insurance company to cover my procedures, but it's certainly possible that they won't, at which point we move on into the court system and I sue for coverage, where similar cases indicate that I would win. My feeling is that it's in the insurance company's best interest to just cover the FFS before then, because a lawsuit gets a LOT of attention AND sets precident, making future denials for others nearly impossible. The appeals process is SO intense, I imagine it's enough to discourage most people from even trying, so the insurers have a clear interest in keeping it intact. Regardless... next week or in three years, I will win and I will proceed, but it's absurd that you practically need to earn a PhD in this stuff in order to get medically necessary care in a liberal state.
I know I know I know that this is getting tiresome, but I need to continue my scenario for you because it's jaw-droppingly silly. The process is just absurd. Let's go. I win. I mean, I'm GONNA win at some point. I don't stop coming for you 'til we're both crying and I get what I want. Time for my surgery, right? Nope. FFS is a very specialized procedure. There are about 8 doctors in the world doing this well, and there are about 5 who do it really really well. Guess how many of these doctors are in my insurance network? If you guessed NONE, you are correct! The terms of my insurance do not REQUIRE me to see an in-network provider, but they DO make me pay as much as 70% of the total cost out of pocket if I choose to see someone out of network. There are actually really good reasons for this - insurers have agreements with in-network providers that keep costs down and limit what they can charge for procedures. Insurers funnel members toward in-network doctors, giving them more patients. Patients have a clear list of specialists to turn to that are known to meet the standards of the insurer. It's an alright system for what it is. For me, though, it's no good. FFS specialists are so incredibly rare that MOST insurance networks will not contain one, and even if they do, they may not excel at the work... not good when your face is being mucked about with.
So what next? Likely the insurance company sends me to their in-network plastics person to have a chat and discuss the procedure. This goes one of two ways. If the doctor is a reasonable, grounded, self-aware person, they take a look at the situation and recognize it as absurd. "I have no experience in doing work with the intent of sculpting new SSCs! I cannot help you! You must see Dr. XYZ, that out of network surgeon you've already spoken with!" they exclaim, and they tell the insurance company as much. We're dealing with plastics people here. though. They are notoriously NOT reasonable, grounded, and self-aware. They tend toward ego and tend not to be SUPER risk-averse when compared with some other specialties. The worst possible outcome for me is that the in-network plastic surgeon declares the procedure to be within their established skillsets. I'm not sure what would happen then, but I imagine it would be a horrible additional set of appeals and arguments. Once I DO get the insurance company to admit that they have no specialist capable of the job in-network, they are required to cover an out-of-network specialist identically to an in-network specialist. The law specifies some distance guidelines that require a specialist that is as close as possible to the patient's home, so the guy I picked to consult with is the closest there is (actually, the guy in Montreal might be a little closer, but leaving the country isn't gonna work). In theory this is the point where we can book the surgery.
I have absolutely NO DOUBT that there will be bumps here that I have not anticipated here, but that's the process that I have started. I'm not sure how to better demonstrate the insanity of attempting to access transgender care than by showing you what I know of my process.
Whoah, whoah, whoah, Rachel. Back things up, here. Maybe we've been able to demonstrate necessity, and sure, equal access to healthcare is a great thing, but you already demonstrated that this stuff is wicked expensive! Wouldn't increases in trans coverage increase healthcare costs? Why should other members subsidize your surgeries? Well. Most importantly, that's kinda how health insurance works. We subsidize your medically necessary pacemakers, and you occasionally subsidize the construction of a new cock, but that's simplistic. Fortunately, the issue has been studied to death. Across even relatively small companies, the cost increases for adding comprehensive transgender coverage to policies has been shown to be so small that it's not measureable. Yup - several studies on it found ZERO overall increase. That's in total cost, not in your premiums. With these pricey procedures, how could the POSSIBLY be? A big part of it is that there are so few of us. The best estimates out there right now peg transgender folks at less than 0.3 percent of the US population, somewhere in the realm of one quarter of one percent. So we're rare critters. That means that there will be a very small percentage of people taking advantage of the coverage. Not every transgender person pursues every available procedure, either. Some won't need FFS, others might not have genital reconstruction. Some of us don't even do hormone replacement therapy. Transgender coverage also tends to be a lot of one-time costs - they don't recur. Once you've had FFS, DING!, you are cooked. The hormones aren't gonna come and change things back. The result is, even providing completely unprecedented transgender coverage to every person with medical coverage in the entire nation would increase total healthcare costs by... not a measurable dollar given margins for error.
Transition is a LONG process, and it is different for each person who undergoes it. It takes years of effort and many, many decisions. My transition will not look exactly like any other out there. This part - FFS - is something that tends to be swept under the rug, and that's a shame, because it needs to be understood in order to be accepted. Hopefully this is a step in that direction.