Trans people in the US face many barriers to competent and affirming healthcare; the healthcare we need isn’t always legal, and even when it is legal to provide us care, providers and systems are systematically unprepared to meet our needs (see my piece on trans care and electronic health records). While these barriers impact every single element of transgender people’s healthcare, including things like emergency care and dentistry, there are extra barriers to care relating to gender-affirming interventions like hormone therapy and surgical care.
One of the biggest barriers to transition care is the referral letter. In order to get insurance coverage and sometimes in order to get care at all, trans people are routinely forced to undergo invasive, clinically unnecessary evaluations to establish whether we are really properly trans enough. The logic is that it is important to establish the medical necessity of the care, but there are lots of surgical procedures that are based on promoting overall quality of life that are based largely on patient choice and do not require the same degree of scrutiny.
Let’s say I want to pursue surgery to change the shape or amount of my breast tissue in order to improve the quality of my life. In order to do this, I will need two recent letters from licensed healthcare providers who can attest that I meet criteria for gender dysphoria, I have been consistent and persistent in my desire to transition, I have reasonable expectations of surgery, I have appropriate support after surgery, and any serious mental health issues are well-managed. Do I have two therapists? No, of course not. Many therapists won’t see you if they know you have another therapist because it’s so opposite common practice. Will my insurance cover me having two simultaneous therapy relationships? Will I be able to take that much time off work or find two therapists who can see me outside my work hours? Are there two therapists in my city and on my insurance plan who are willing to write these letters (and in my case, who I’m not already friends with)?
Let’s say instead I want to have a different surgery. I happen to have pectus excavatum, a congenital condition in which the sternum and ribcage develop in the wrong shape, creating a visibly concave chest. This can put undue pressure on the heart and lungs and cause pain and difficulty with exertion. In severe cases this is generally corrected in childhood, and my case wasn’t severe enough for that. However, it’s caused consistent quality of life issues because I do experience all of those symptoms, and it’s become an increasing concern following things like pneumonia and lung collapse that put my lungs under even more stress. Because of this, my case is in this borderline area where nobody is pressuring me to get this fixed but I could decide that it’s worth doing. This is a dramatically higher-risk procedure versus breast tissue surgeries. It is traditionally an open-chest surgery, in which cartilage is removed and the sternum is broken and repositioned using metal implants that will need to be removed following healing.
Even though this procedure is higher-risk than gender-affirming chest surgeries, even though it requires much longer post-operative inpatient care and is thus more expensive for insurance companies, even though the healing period is dramatically longer, and even though I’m more likely to be dissatisfied wtih this surgery than trans-affirming surgeries, it would be dramatically easier for me to access this surgery, and I could get it without ever discussing it with a therapist, JUST because it isn’t gender-affirming. If I were getting it for gender reasons, it would become a mental health concern and I would need not just one but TWO therapists to affirm that I am really who I say I am and I am competent to make that decision. Even though our community is at incredible risk of poverty, non-insured status, and refusal of care due to clinical discrimination.
Some clinicians have tried to get around the ethical problems with gatekeeping by adding services to the letter-writing process, trying to make the process valuable to trans people. While I think this is often really well-intentioned, it often drags the process out longer for people who don’t necessarily need those services, who wouldn’t be forced to get them if they weren’t trans, and who may not be able to afford them. I think pre- and post-surgical counseling should absolutely be available for all kinds of surgeries because surgery can be massively life-changing and often people don’t have good support in thinking through how to prepare the care and support they’ll need. But trans people shouldn’t be forced to buy that counseling just because we’re trans, no matter how valuable a service it might be.
As clinicians, we need to tell insurance companies that these approval requirements are discriminatory and hurt our relationships with vulnerable clients by violating their bodily autonomy. And in the meantime, we should get trans clients through the process as painlessly as possible and then really offer them the support we can offer, so they can freely decide based on their needs and resources.
After I made this video I also learned about the forthcoming book The Care We Dream Of, edited by Zena Sharman. I really enjoyed Sharman’s last book, which I think I cite in this video, and was excited to order The Care We Dream Of as soon as I learned about it.
Han Koehle 