With Pvt. Chelsea Manning back in the news for requesting to be treated for gender dysphoria at a civilian prison, many people have questions about what this means. What is “gender dysphoria,” exactly? What does it have to do with a gender transition? How is it treated? Why does Manning have a right to this treatment, and do all trans people need treatment? The topic can be confusing, but it boils down to a few essential points on what you need to know about transgender medical care:
1. Gender transition-related care is essential.
The term “transition-related care” is a catch-all phrase that refers to a range of treatments available for transgender people who are experiencing gender dysphoria and need some kind of healthcare intervention to feel an alignment between our gender identity and our bodies—in other words, to “transition” into a physical and/or mental state that is more comfortable for us. Some treatments that fall within transition-related care include psychotherapy, hormone treatment, and gender confirmation surgeries. Not all trans people need the same kind of transition-related care, or any at all. But for those who do, this is essential healthcare required to ease dysphoria and allow a trans person to live a full, safe, and fulfilling life.
“Gender dysphoria,” in turn, is a term that describes “discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth,” according to the World Professional Association For Transgender Health (PDF). It is also the current term in the DSM-V that is used by mental health professionals to diagnose trans people (such a diagnosis is required by insurers for transition-related care to be covered). Not all trans people experience dysphoria, or experience it the same way. But for many of us, dysphoria is a serious condition that makes it impossible to fully experience our lives without transition-related care, due to our own distress as well as how others see us in a world that is largely defined by gender. With twice the unemployment rates, nearly 20 percent of trans people being refused housing due to gender identity, and 41 percent reporting having attempted suicide, the long-term effects of living with dysphoria can be catastrophic. In contrast, transition-related care often largely counters these effects. For example, 78 percent of trans people who have transitioned from one gender to another report feeling more comfortable at work and having improved job performance (PDF).
Transition-related care may fully ease the symptoms of gender dysphoria, allowing a trans person to live just like anyone else, or some ongoing care may be required throughout life.
2. Trans people often have difficulty accessing transition-related care.
Unfortunately, there are many common barriers to accessing this essential health care. Medical providers serve as gatekeepers, meaning that trans people have to find competent, sympathetic providers who are willing and able to deliver such care. CJ, a trans person from California (who uses the pronoun “they”), was able to find a one-year job that would provide insurance coverage for a surgery they couldn’t afford, but they recount that it took “several months and hoop-jumping to ‘prove’ I needed an appointment to see a very busy qualified surgeon.” By the time CJ jumped through those hoops, they couldn’t schedule a surgery before their job ended and their coverage expired.
Financial barriers are often the greatest barriers to transition-related care: those who find a competent provider, as CJ experienced, may not be able to pay for expensive treatments such as hormones and surgeries, especially since transgender people are nearly four times more likely to have a household income of less than $10K a year compared to the general population (PDF). These rates of poverty are even higher for trans people of color.
Mara Keisling, Executive Director of the National Center for Transgender Equality, noted that “there are still a lot of people in the public, and even in the medical profession, who don’t understand that transition-related care is medically necessary, efficacious care needed to treat a serious condition. Our health care is still stigmatized.”
While five states (CA, CO, OR, VT, and CT) and Washington, D.C. have issued regulations that prohibit private insurance exclusions on transition-related care, even in those states not all insurance plans are included. Some private plans aren’t regulated by the body issuing the regulation, and those who financially need the coverage most — those on Medicaid — often face exclusions. Only California and D.C. expressly cover transition-related care for Medicaid recipients, while many states have specific exclusions. Advocacy organizations are working to close this financial gap, but in the meantime, many trans people cannot access the care they need, especially if they need surgery.
3. Different trans people need and receive different kinds of transition-related care.
Many people assume that transition-related care is a simple path from therapy to hormones to surgery, but this is not the case. While financial access barriers keep some of us from accessing needed treatments, others don’t want or need surgeries or hormones. Many trans men, for example, have no interest in genital surgery because the results currently available are not ideal. Many genderqueer and gender-nonconforming people don’t have any desire to change our bodies, since our identity does not “match” any particular body type. Contrary to popular belief, there is really no such thing as “the surgery” for many trans people. The current standards of care for trans health, issued by the World Professionals Association for Transgender Health (PDF), emphasize the importance of informed choices for trans patience and flexibility for providers, and recognize that financial barriers affect the care that trans individuals are able to receive.
This flexibility is also important for policies related to trans people in general, such as the laws and regulations that allow trans people to change our gender marker on official identity documents. Trans advocates have long stressed that these policies should not require any particular medical treatment, since trans peoples’ individual situations vary so much in terms of desired and available care. Fortunately, many state and federal policies now acknowledge this and allow trans people to change ID with the sign-off of a medical provider, rather than requiring a specific treatment.
4. Trans healthcare isn’t just about medical transition.
While much of the discussion around trans healthcare focuses on transition-related care, trans people also face access issues and discrimination around primary health care. Nearly 20 percent of trans people report being refused medical care due to being transgender, while half of trans people surveyed reported having to educate their medical providers about their own healthcare. Of those surveyed, 28 percent reported having to postpone care due to discrimination when sick or injured, while 45 percent had to postpone care because they couldn’t afford it (PDF).
Fortunately, the Affordable Care Act (ACA) has allowed many trans people who weren’t previously eligible to access insurance. The ACA doesn’t allow insurers to refuse trans people coverage or charge us more just for being trans. It also prohibits discrimination based on gender identity in covering routine care such as breast, cervical, and prostate cancer screenings that some trans people were previously denied. However, the ACA is still new and we don’t yet know exactly how trans people have been affected.
5. Appropriate medical care allows trans people to live fuller, safer lives.
It is difficult to quantify the extreme benefit trans people enjoy when we are able to access appropriate medical care. “For some people it is absolutely life-saving,” Keisling of National Center for Transgender Equality said, continuing:
“I was just talking to the mother of a 16-year-old who has been on hormone blockers and [...] this summer she’s having surgery. She’s going to get to live her last two years of high school feeling anatomically correct and launch into her adult life absolutely indistinguishable from any other woman. She’s ecstatic and her parents are ecstatic and it’s just amazing. It will absolutely define this woman’s life in ways that mine wasn’t allowed to be defined. I had to spend most of my adult life trying to figure things out. She’s allowed to live up to her full potential as early as possible. And we should want that for everybody.”
[World Professional Association For Transgender Health: Standards Of Care For The Health Of Transsexual, Transgender And Gender-Nonconforming People (PDF)]
[Injustice At Every Turn: A Report Of The National Transgender Discrimination Survey (PDF)]
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