The past few years have ushered in a new era of visibility for the transgender (trans*) community. From Amazon’s breakout hit Transparent to Laverne Cox’s groundbreaking cover of Time magazine, trans* individuals are seeing their previously overlooked stories reflected in mainstream culture. And let us not forget Bruce Jenner’s heartfelt coming-out interview with ABC’s Diane Sawyer, which has positioned them as the most bearable of the Kardashian women.
These trends in popular culture, coupled with the July 2014 ruling by the Department of Health and Human Services to cover gender-affirming surgery under Medicare[1], provided victories for a historically marginalized segment of the population. However, these victories are not enough; while the Patient Protection and Affordable Care Act prohibits discrimination based on gender identity, there are only 24 private insurance companies which currently offer coverage of procedures and services needed for transgender-related care.[2] Trans* people who choose to utilize Hormone Replacement Therapy (HRT) and/or surgical procedures may be left with a large financial burden in order to affirm their true gender identity
In order to ensure that trans* individuals are able to access medically necessary care, it is imperative to advocate for the coverage of transition-specific costs that are incurred exclusively by this community. This can most easily be achieved through a national mandate to include full coverage of these specific services, which several states and municipalities have already instituted. Once marginalized and stigmatized by mainstream culture, it is now time to extend access to adequate health care to the trans* community to allow the affirmation of gender. This is a basic human right which can no longer be denied.
Once a gender identity diagnosis has been obtained, a person may begin the process of transitioning to their respective gender. This process includes counseling, legally changing one’s sex, living for a period of time as the desired gender, hormone therapy and, the option of pursuing gender reassignment surgery.[3] Of note is the emphasis the World Professional Association for Transgender Health (WPATH) places on the medical necessity of transitioning once a gender identity disorder has been established; a 2001 report highlights that this process is “not experimental, investigational, elective, cosmetic or optional in any meaningful sense.”[4]
Far too many conceptualize the decision to transition as an elective decision. While there is an element of choice, this only extends so far as to decide whether, and to what extent, transitioning is viable for the individual, not in the sense of cosmetic vanity. Contemporary literature and physiological research on this indicates that being transgender and living in an improperly gendered body presents physical issues of sexual expression and mental health concerns. Transgender individuals have higher rates of anxiety, depression and suicide than the cisgender population, as well as decreased life expectancy due to higher rates of illness and violent victimization.
Despite the absolute necessity of being allowed to medically transition to one’s rightful gender if desired, all too often these services are unattainable due to their staggering cost. A male-to-female (MTF) opting for the full range of surgical procedures can expect to face costs between $40k and $50k, while a female-to-male (FTM) intending to transition faces an estimated $75k in surgical expenses.[5] These approximations have been calculated under the assumption that the individual has undergone counseling and hormone therapy, which are additional financial burdens incurred prior to surgical expenses.
Complicating these already high costs is the income inequality seen between the transgender and cisgender population. The National Center for Transgender Equality reports that trans* people are four times more likely to live in extreme poverty.[6] Employment rates among the trans* community are well below the national average, barring many from employer-provided insurance.
Continuing to demonstrate the economic burden placed on trans* individuals because of their gender identity, Spade (2010) illustrates the ties between barriers to care, barriers to accurate identification papers and access to health care: “many ID-issuing agencies will not change gender markers on ID for transgender people without evidence that the person has undergone surgery…the employment consequences related to lack of accurate ID are directly connected to healthcare access issues.”[7] Considering that it is still legal to terminate an individual’s employment based upon gender identity in over half of the states in the US[8], there a serious economic disadvantage to the trans* community which must be factored in to policy discussions of mandating coverage of care.
This trending economic inequality, compounded by barriers to the medical care and oversight needed to transition, has led many trans* individuals to turn to risky behaviors to procure the items and/or funds needed to successfully transition. Unable to afford hormone therapy, countless trans* people turn to illegally procured hormones to begin their transition. These black market, medically unsupervised ‘street hormones’ are often easier to access and the only economically viable option.
In an interview with OUT magazine, actress Trace Lysette (cited in the 2011 article as Trace Mizrahi, a nod to her House affiliation in the ballroom scene) opened up about her own transition story. She recalls moving to New York, where she “worked at MAC and escorted to pay for the hormones and surgery….my vagina alone cost $15k.”[9] Forced to turn to sex work to fund her transition, Trace recalled being able to ‘graduate’ from escorting to stripping after her physical transition was complete. Her openness about her past, as well as her ‘coming out’[10] in Hollywood, have been lauded by many, perhaps signaling a new era of trans* acceptance. Trace’s story may be one of eventual success, but unfortunately this is not the case for far too many trans* individuals.
A robust body of literature has emerged that supports the implementation of a health care mandate to cover the cost of transitioning with health insurance. As has been demonstrated, there is a financial burden unjustly placed on members of the trans* community who wish to transition, as well as serious health risks involved in transitioning without medical supervision and/or engaging in high-risk behaviors to fund transition. While there is a high cost to transition, a mandate would theoretically spread the cost among a large pool of stakeholders.
With no mandate, the cost for a single individual would be very high; however, once spread out over the entire pool of insured individuals, the proposed mandate would generate a minimal monetary impact on individuals not directly using the mandate. Given the disproportionately high risk that trans* individuals incur, the demonstrated benefit of increasing access to transitioning is the reduced cost of long-term health expenditures, as well as added life-expectancy. When juxtaposed with the benefits, it becomes clear that it is both a legal and moral imperative to mandate coverage of gender-affirming procedures.
There is precedent for mandated coverage; city officials in San Francisco set aside $300k to fund gender reassignment surgery for poor and uninsured residents in 2014. Also of note is that San Francisco was the first municipality to cover these services for their employees, which was implemented as a part of their health care benefits in 2001. City officials are calling the program a success, and have allocated $500k from the 2015 budget to continue to provide the service for the city’s most vulnerable.[11] Budget analysts for San Francisco have indicated that the program is successful because of the relatively low number of people that are in need of this coverage; transgender residents comprise an estimated 1% of the city’s population. As such, the life-changing impact this policy is having on San Francisco’s trans* community proves not to be a financial burden on the city budget.
The need to extend coverage to include transgender-specific issues is hardly a debate; rather, it is an affirmation of gender expression and basic human rights. We have reached a pivotal moment in the trajectory of human rights in the United States. From the Supreme Court hearing arguments for marriage equality to the increased visibility of trans* issues in 2015, the time to act on mandating trans*-inclusive coverage is upon us. Outdated are the scholars who assert it is not medically necessary to transition, and the stark realities facing transgender Americans can no longer be ignored. While stigma and discrimination may still haunt this community, policy makers and activists can fight to legitimize trans* identity. By mandating coverage for transgender-specific health care, we can take the first step forward in ending the existing reign of intolerance.
[1] Decision No. 2576. 2015. (Departmental Appeals Board, Department of Health and Human Services).
[2] “Finding Insurance for Transgender-Related Healthcare.” 2015. Human Rights Campaign.
[3] “Finding Insurance for Transgender-Related Healthcare.” 2015. Human Rights Campaign.
[4] Standards of Care for Gender Identity Disorders. 2001. World Professional Association for Transgender Health.
[5]Bernstein, Lenny. 2015. “Here Is How Sex Reassignment Surgery Works.” The Washington Post.
[6] Transgender Americans Face Staggering Rates of Poverty, Violence. 2015. National Center for Transgender Equality.
[7] Spade, Dean et al. 2010. “Medicaid Policy and Gender-Confirming Healthcare for Trans People: An Interview with Advocates.”
[8] “Paying an Unfair Price: The Financial Penalty for Being Transgender in America.” 2015. Movement Advancement Project.
[9] Thrasher, Steven. 2011. “Paris Is ‘Still’ Burning.” OUT.
[10] Kellaway, Mitch. 2015. “After Years of Hiding in Hollywood, Trans Actress Trace Lysette Is Finally ‘Living Out Loud.’” The Advocate.
[11] Roberts, Chris. 2014. “Transgender Surgeries Funded by San Francisco Called Successful.”
