Why is gender affirming care so expensive?

I’ve written quite a bit about the costs that I have incurred along my journey of trying to inhabit a trans body. But even as I look forward to the upcoming revision surgery on my vulva, it is a harsh awakening to realize that I am going to have to spend yet another $6,000+ for housing simply because Seattle has no transgender vaginoplasty surgeons and most insurance refuses to pay for out of state surgery costs.

So how much have I paid out of pocket so far for gender affirming care?

  • $5,000+ for electrolysis and laser hair removal on my face and body (not considered “essential” by insurance)
  • $9,500 in travel costs for consults, surgical recovery housing, and post-op appointments
  • $6,000+ for housing for revision surgery recovery

All told, I can account for over $20,000 in costs that insurance refused to cover.

I am one of the lucky ones. I am privileged enough to have a good job with decent health insurance so my co-pays are minor and I can afford to save up for these procedures. And I have a large network of friends who have generously donated over $5,000 towards those costs.

But can we talk about why these costs exist in the first place? Why is it considered ok for transfeminine people to have to pay for face and body hair removal to deal with dysphoria? In a world that demands that we “pass” as women to use public facilities such as restrooms, that is incredibly classist and discriminatory. And why does insurance not have to pay for the costs of getting an out of town surgery when there are no local surgeons available? My insurance now pays for cancer patients to get out of town specialty care but despite my advocacy for the past several years, continues to deny trans people that same right.

Luckily, starting in 2022, insurers in Washington State are now going to be required to pay for all doctor-prescribed gender affirming treatments and will no longer be allowed to label them as “cosmetic”. This is thanks to the tireless work of many many advocates and organizations who fought for years against insurance denials. And I hear through the trans rumor grapevine that Seattle may FINALLY be getting a surgeon soon who can perform vaginoplasties locally. But while that helps people here in Seattle, that doesn’t change the fact that far too many trans people around the US aren’t given equal healthcare access. We need laws in place federally to mandate coverage of gender-affirming care.

So next time you think of asking someone if they have had “the surgery” or make any kinds of assumptions about what trans people should look like, think about how expensive it is to look like I do. How inaccessible it is to the vast majority of trans people in this country to achieve what Laverne Cox, Caitlyn Jenner, and Elliot Page have done. And if you have resources, I encourage you to donate generously to your local trans fundraisers and places like the Jim Collins Foundation to help more trans people get the care we so desperately need.

How I knew I needed Surgery

Content Warning: I’m going to talk explicitly about sex in this post.

How did I know I needed surgery? It is a question I get a lot in different forms and it’s a good question, particularly for other trans people to ask each other.

My earliest inklings were from when I first learned what vulvas were. I was immensely curious as a child so I secretively turned to my local library and sex education websites to find out what women had that made them so amazing and supposedly so different. That’s when I found out the beauty that was the human vulva, vagina, and especially, the magical clitoris.

What was initially curiosity quickly turned into an obsession. And I doubt it was the same kind of obsession that my cisgender peers were starting to have as their libidos awakened. It crept into my psyche and my dreams. It wasn’t long before I was having both sleeping dreams and daydreams that involved strong, powerful women with both penises and vaginas. Because to me, the peak of human achievement would be having the best of both worlds. This was before I even knew that trans or intersex people existed.

It took me years of suppressed queerness before I finally admitted those dreams in group therapy as an early adult. And in the meantime I went through phases of hyper-masculinity as I tried to reconcile these desires to experience a vagina that kept pestering my brain. When I first had oral sex with a woman, the obsession only grew.

Eventually I finally got enough exposure to trans people that I realized I was one too. Not out of peer pressure like the media tries to paint it, but from seeing examples of people like me. I started out slowly and it took me awhile of my social transition before I decided to take any medical steps. You can see a lot of that progression if you read the early posts on my blog.

I had a lot of hesitation about starting estrogen because I was worried it would change how my already anxious/depressed brain worked. But once I started, I knew I could never go back. After the initial adjustment period, my brain had never felt more “right” and like I finally had the right operating system installed. But it did fundamentally change how I experienced sex.

I have always been hesitant and anxious about using my penis. But after starting hormones, there was some significant rewiring of my nervous system that took place and changed how I felt sensations. Suddenly an appendage that felt like a blunt tool now felt like a fine tip brush. It honestly felt like I imagine an inverted vagina would feel with a clitoris on the tip. My sensitivity increased immensely and I also lost all desire to use it for penetrative sex.

I had already started to think about surgery but my initial explorations had all been about whether or not it was possible to have a vagina and a penis simultaneously. I thought for sure that’s what I wanted because that’s what all my dreams still involved. I scoured the internet and couldn’t find anyone except naysayers who claimed it was anatomically impossible.

Finally, the first surgeons started to do what they called “penile preservation vaginoplasty” and my dreams were vindicated! Except ironically, by the time I discovered that, I was beginning to realize that it wasn’t what I wanted. I came to understand after almost 2 decades of dreaming that that form was more about what I was attracted to, not about what I wanted for myself.

Once I finally accepted that I wanted a vaginoplasty, the rest was just about getting through the medical gatekeeping. Last year when I went for my consult, I was sure that it was what I wanted. Now I am 120% sure and for months now I have been counting down the days (12) until I could finally achieve what I’ve secretly desired for so long.

I’ve been trying to decide for a couple years now if I am asexual or if I just have a low libido and as I think about life post surgery and all the sex I can have uninhibited, I think I finally have my answer. I just needed the right parts!

I’m in the home stretch now and I’ve started taking the pre-surgical meds. The Gabapentin is making my brain a bit hazy and I’m rather scatterbrained so hopefully this blog post makes sense. But in 6 days I pack up the car with my partner who will be my caregiver and her partner who lives with us and we drive down the coast to San Francisco.

12 more days!

Insurance approval

I know to most cisgender people this doesn’t sound significant but I just got word from my surgeon’s office today that I got insurance approval for gender confirmation surgery!

This is one of those things that should be a normal occurrence. But for trans people, we have had to fight so hard for generations to get these surgeries covered by insurance that it is still a big deal for us to have these basic rights. I remember not that long ago when my friends were going to Thailand because that’s the only way most people could afford to get surgery out of pocket. And because of that legacy, there are still so few surgeons in the US that even those of us in major cities like Seattle have to travel out of state and incur huge expenses to get these surgeries.

It’s also significant because of the amount of medical gatekeeping we have to endure to get there. I can’t think of a single procedure where a cis person has to get more than one letter of support. But most trans people require 3 letters from MDs, therapists, and PhD level psychiatrists to get this insurance approval.

For me, I got these letter last fall because I was told the surgeon was going to ask for insurance approval in late winter. But they waited too long to submit paperwork so I had to go get the letter updated because they needed to be within 6 months. Which meant that the first time around I got an insurance denial which was scary even though I knew why.

The point of this story is, if you have the authority to be a medical gatekeeper for a trans person, PLEASE make it as smooth as possible for them. There are a variety of reasons that trans people don’t want surgeries and shouldn’t need them to transition. But for those of us who do, we are usually overwhelmingly sure that this is what we want. So don’t make it harder for us than it needs to be. Trust us to be the experts on our own experiences. And if you get asked for a perfunctory piece of paper, just sign it.

Boob update

2 years and 1 month into hormones and my boobs are still growing! At this point I’m solidly a C-cup but they are pretty conical and haven’t rounded out so I don’t really have cleavage yet. Other than the shape and distance from each other, this is about what I was hoping for. It makes me so happy to see them in the mirror or my peripheral vision!

For my fellow trans health nerds who are wondering, I started by ramping up to 6 mg of oral estrogen sublingually spaced throughout the day and eventually backed down to 4 mg where I am now. I never added spironolactone (an androgen blocker) because my testosterone disappeared and never came back. In February this year, my estradiol level was 139 pg/mL (cis woman range is 12-498 depending on cycle) and serum testosterone was only 13 ng/dL (cis woman range is 8-48).

Do Trans Women get Periods?

Do Trans Women get periods? Absolutely.

As someone who is on my period now, I can tell you that it is very real and it sucks. I am ready to burst into tears at a moments notice and I could definitely bite someone’s head off right now. I’ve been tracking my mood cycle lately to confirm that it actually does follow a monthly pattern and my app was spot on this month. And it is synced up with my nesting partner so I knew it was that time without even asking her.

Do we bleed? No. But if you try to point out how “lucky” we are are some BS like that, I will slap you. Because that is a really sore point for someone like me who wants nothing more than to be pregnant. But I also know that it is unlikely to be possible while I am still young enough to do it because while uterine transplants are absolutely medically possible, they are only given to cisgender women.

The period is mostly caused by being on estrogen but I have always been sensitive to monthly cycles. Years ago before I had admitted to myself that I was trans, I noticed that my mood cycles were related to where my partner was on her period. But now that I am on estrogen it is a whole lot more emphasized.

And in case you think I’m making it up, you should read what other trans girls say.

Going Through the Motions

Being in transition for me feels like everything in my life is temporary. For the past 2 years I’ve been taking all these steps to try to feel like a normal human. This week is my two year anniversary of being on hormones and I’ve also had my braces for over 2 years now as I get my bite corrected. I’ve been getting hair removal all over my body and preparing for bottom surgery. I’m been doing all the necessary things to treat my gender dysphoria and address other medical problems that I’ve been putting off for when I had good health insurance. But all these things just feel like going through the motions in hope that on the other end I can rejoin the real world and live the life I actually want.

Many days I feel like a ghost, like an interloper from another plane of existence trying to navigate a world that isn’t built for me. I feel like I can interact with the real world but I’m not a part of it yet. Like I need to somehow “earn” my way into that life by doing all the right things. And in the meantime my life feels ethereal and temporary, like it could all be washed away by a really bad day.

And now with all of the Seattle area on lockdown for this COVID-19 pandemic, life feels even more temporary. It’s hard to make plans not knowing how long this will last. And scary to know that my surgery date could be effected.

It’s not that I’m afraid of dying; in fact that’s partly the root of the problem. I don’t feel any attachment to living because most days I feel like I never actually have. I’ve never fully lived the life I want as the person I want to be yet so I have no stake in protecting that. The only thing that keeps me going is the hope that after all this transition work, I can actually have that life. I don’t know if it will be better or feel more real, but it’s the only anchor I have to reality right now.

And now that I’ve lost a lot of my routines and physical interactions, even more of my life feels unmoored. I feel like I’m adrift in a world that is panicking and chaotic while I sit here at home mostly feeling numb. I keep saying that I’m ok but if I’m honest I’m not really. I’m spending most of my time dissociating by playing video games to fully immerse myself in a different reality. A reality where I have achievable goals and can actually go out and kill the bad guys and save the day. Don’t get me wrong, the video games are essential to my survival right now. But they are also part of this temporary feeling where the real world isn’t real to me.

I’m not sure when these pandemic measures will all end but I keep holding on to the hope that I will still be able to have surgery in August. And that surgery gives me some grounding in my body and in the real world. Because I do want to live. I just don’t know how to yet.

My decade in review

I started this decade still thinking I was mostly a man and mostly straight. I had just gotten married in what I could already tell was a terrible relationship and I stuck with it for 6 years because I thought that I would never be loved for who I actually was. And because of that, I put all my gender and sexuality questions on the back burner for over 5 years.
 
I’m beginning this decade with a new name and a much clearer picture of who I am. I’ve finally recognized why I was always different and claimed the complicated womanhood that I always had. I have built a stronger queer community and found more love than I could have possibly imagined.
 
Transition and self exploration are hard work. But with my gender confirmation surgery coming up in 7 months, I feel like the hardest parts are almost over. If I can make it through this year, I will hopefully have some relief from the intensity of dysphoria that has been in the background since puberty.
 
There is light at the end of the tunnel and I know that I’ve made it this far because of the many people who have supported me and made this corner of the world a safer place to be myself.

1 year without a beard

Today is the 1 year anniversary of me shaving off my beard. It was a big scary leap for me to give up something that had been such an important part of my identity for 12 years and accept that I would have to deal with more dysphoria for awhile as I dealt with the facial hair. But I’m so glad I did.

I’ve now had 5 sessions of laser hair removal on my face and spent over $2,000 in the process but all the pain, time, and money paid off because now I’ve gone a week without shaving and my face is still smooth! I have no more stubble or that dark shadow on my face and the amount of hair I have left to pluck isn’t any more than many cisgender women have to deal with.

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In other news, I’ve conquered two of my biggest fears around bathrooms so far. I’ve used a women’s room at a mall (with my spouse), and I’ve had a conversation with a coworker in the women’s room at work. Both things that I never would have felt safe doing with a beard.

This transition has been expensive and I’ve managed to make it this far with the help of my spouse but I still need to raise another $5,000 for my bottom surgery next year. If you are able to contribute I would really appreciate it. https://www.gofundme.com/f/haven-gender-confirmation-treatments 

A new life

It’s been a little over 10 months since I shaved my beard and almost a year since I started using my new name everywhere and already it feels like another lifetime and another person. I’m still getting photos from a year ago popping up in my Facebook memories and it is hard to even recognize them as myself. I can see that the person in (some) of the photos is beautiful but it isn’t me anymore. I have moved so far beyond who I was in that moment.

The first few months after shaving were definitely rough with having to face my dysphoria around my chin and stubble. But now there is so little hair left that I don’t have to think about it 90% of the time and I often forget to shave the few stubborn hairs around my lips. I feel so much more feminine now without the shadow on my face.

It also helps that I can really visibly see the changes that estrogen has made in my body. My facial structure has been changed by both rounding of the edges from hormones and from a pretty distinct cheek structure change created by the first jaw surgery. Many acquaintances I see think I have already had the feminization portion of the surgery which feels great. At this point I’m feeling more excitement than dread about the second surgery and the final results I’ll have. Especially since I can finally get this annoying metal out of my mouth and feel confident smiling again.

There are still a lot of hurdles to cross. I’m trying to get the letters from the psychiatrists that I need for surgery and the hair removal on my genitals to prep for that. I have appointments today and next week that should hopefully cover those barriers.

I also started vocal feminization lessons last week. While my voice has subconsciously raised a few degrees already, estrogen doesn’t automatically bring your voice back to where it was before testosterone (yet another reason to support hormone blockers for trans teens). I have to do a lot of conscious work to expand my upper range and retrain my muscles not to create the masculinized resonance my vocal cords are used to. Someday it will hopefully be second nature but for now it is exhausting work.

However, I do seem to have crossed some magical threshold now where many people in public recognize me pretty quickly as a trans woman. Whereas before with my beard I would get stares of befuddlement everywhere I went, now I mostly get recognition, at least in liberal Seattle.  Which has meant that I get a lot more “ma’am”s and “she” either automatically or from self correction.

I tried using she/her pronouns before just around my chosen family but it still felt grating at the time. Like I was too far away from that reality and the pronouns just reminded me that no one would automatically assume that. But now I have decided to use them again as another option in addition to they/them and it feels wonderful. Especially when it is coming from strangers who I am first meeting.

In the moment, progress can feel so slow but it is nice to have these moments where my head comes out of the water and I feel like I can breathe again.

What it takes to change your government gender

I received my new Drivers License today which means that I’m officially a doctor certified, government recognized woman! It also means I’m done with phase 1 of changing my name and gender marker. But you wouldn’t believe how complex the steps to get there can be. Here’s what it takes in Washington.

First I had to research the process and figure out which dependencies were built in so that I could get the necessary documents at the correct government office in the right order. Then  I had to go to my doctor to get the required letters and signatures.

Step one was going to the local County Courthouse and filing a Petition for Name Change which had to be submitted by 11 am if I wanted a same-day hearing and I had to pay $215 in cash to get the 4 certified copies I would need later on. Then I had to come back at 1:15 to have a judge have me attest on the record that I wasn’t changing my name to commit fraud or escape debt. Then I waited around in the lobby while my documents were processed.

Once I had the name change, I was able to submit my passport renewal in the same office but I nearly made the mistake of filling out the renewal form because that’s what the online steps indicate if you say you are changing your name. In order to find the correct steps you have to find the deeply hidden page on how to change your gender which tells you to submit the application for a NEW passport (Form DS11) in person and means you can’t use the online wizard completely (you have to tell it you don’t have a former passport and then correct it by hand after you print) or submit by mail. I also had to be prepared with a new passport photo which cost me $15, a letter from my physician certifying that I had medically transitioned, and pay $145 in the form of 2 checks to submit along with my previous passport which means I can’t fly abroad until the new one arrives.

Then I proceeded to the local Social Security office where I waited for an hour in a crowded lobby full of armed officers to submit my Application for a Social Security Card showing the correct gender which required me to show my court order along with another copy of the letter from my doctor certifying my medical transition. Luckily that process was free.

Then I proceeded to the Department of Licensing to update my Drivers License only to find out that to update an Enhanced ID (necessary for flying soon), I needed to wait for the new Social Security Card to arrive in the mail. So I came back a week later and waited in line a second time to submit yet another Change of Gender Designation Form with my physician’s signature along with another copy of the court order and a $10 fee.

Luckily for my Birth Certificate, I was able to mail in the Request to Change Sex Designation on a Birth Certificate for an Adult which had to be notarized but luckily doesn’t require a doctor to sign anything now in Washington. I did have to pay another $20 by check if I wanted to get a copy however.

All told, this is how much effort it took:

  • Research Time: 3 hours
  • Number of Offices: 4
  • Wait Time in Lobbies: 2 hours
  • Cost: $425

Now I get to move to phase 2 where I contact all the various places that have my old name such as banks, medical providers, online accounts, etc. to get them to update my name and gender as well. I’m exhausted just thinking about it!

If you would like to help support my transition costs, you can donate at https://www.gofundme.com/f/haven-gender-confirmation-treatments