The Rock vs. The Hard Place

Ah, the wonders of modern medicine. Hawaii has some pretty great laws when it comes to insurance coverage. Work over 20 hours a week at the same place? You can be covered. Make less than $20k per year (or so) per person? You can be covered.

The biggest problem with this system is how often you will get hired to work 19 1/2 hours per week so your employer won’t be required to insure you, this happens a LOT, even with governmental, state jobs. Also, a person like me, who relies on medical treatments often enough, must consider whether or not it is worth making more than $20k per year. As it stands, Medicaid for me and my wife is entirely free. Doctor visits? Free. Therapy? Free. Perscriptions? Free.

If I worked at a job and made $30k per year, it is quite possible that the money withheld from my checks, along with co payments for treatment would actually cost me more than $10k per year, so there is some incentive to earn less, and stay close to the poverty line. Yes, trans world problems.

Then there is the whole being trans thing, and how insurance companies view it. Medicare recently changed their views on trans treatment saying it is no longer experimental and they are opening the doors to allow coverage for sexual reassignment surgery (SRS), gender reassignment surgery (GRS), gender conforming surgery (GCS) or, a sex change (The OPERATION), depending on what you want to call it. That is right! If you are retired, you now qualify for a vagina! Yay! Vaginas!!! This has caused a great controversy because it is commonly thought that such surgery is cosmetic. I would agree, if I spent my days naked from the waist down.

As Medicare goes, so goes the rest of the insurance industry, so in due time, many companies will likely start covering trans related care. BUT, all this focus is on the surgery, and anyone who is transitioning knows, surgery is just one small piece of the pie. I love puns.

Hormone replacement therapy (HRT) is the bread and butter of trans care, and HRT is required for at least a year in order to get, “The operation”. Also required? Real life, full time experience, of living as your preferred gender for twelve or more consecutive months. For a butch-ish lesbian like me, that full time experience thing is a bit confusing. Same goes for the gender fluid folks out there and whatnot. It takes a lot of time and effort to make this 38 year old face and body look even remotely female. My name is not yet legally changed, so there are times when I just have to show up as a male because I need to show my ID. There are other times where I just do not wish to pull attention away from the event I am attending, by presenting as a female. Yes, I do get a lot of extra attention. Most of it is positive or simple curiosity, but I am not that woman who stops men in their tracks because she is good looking… yet. Also, creating an entirely new wardrobe is expensive, and my body is going through some rapid changes that make things that were too small one day, too big the next, or vice versa. Unless I wish to wear muumuus all the time, I kinda’ have to pace my wardrobe expansion, particularly on my budget. Many people have made very generous donations to my ever expanding closet… fortunately there is more room in there, now that I am completely out of said closet.

Back to hormone therapy, it is required for twelve months, at least, before surgery is allowed. Also, HRT is the primary cure for gender dysphoria. Giving the brain the proper hormones has an immediate and profound effect on mood. But again, most insurance policies and companies consider hormone therapy to be cosmetic or experimental. It certainly does cause profound physical changes, but the healthy mind is the most important thing to me and many other trans folk. In other words, if transition were truly just cosmetic, I would always do drag and avoid the medical loopholes entirely.

Speaking of loopholes, they are what get my treatments covered. My therapy was once rejected by my insurer because the primary reason my therapist listed for my visit was my oh so transy transness instead of say, my suicide attempt and depression. Of course, he did also mention those things but they were deemed moot by the insurance company because well, he mentioned my need to transition first. He had to resubmit, stating I was suicidally and clinically depressed, and then he only briefly mentioned I am trans at the end of his notes. This time, lo and behold, I was covered. Good thing I was suicidally depressed! I am the first and only client my therapist sees, to have been rejected by an insurer. My crime? Being trans.

Then, there is my primary care provider. You know? I have high blood pressure, so my doctor has prescribed me with a blood pressure medication that also has some odd side effects. It shrinks my prostate and prevents my body from using any of the testosterone it produces. My blood pressure is much better now.

Also, my doctor has determined that I have an undisclosed endocrine disorder which he uses injections of estrogen to treat. Fortunate for me, he can say it is undisclosed and get my policy to cover it. If he discloses what my endocrine disorder actually is, you guessed it, I would not be covered.

What my therapist and doctor have to do is legal, and technically true, but we would all feel a good bit more legit, if we could just disclose the FULL truth and still get coverage. Gender dysphoria, like I say in almost every single blog post I write, is a killer. High suicide rates, extremely high suicide attempt rates (10-30x the national average which is somewhere between 1.5 and 4%), and even higher rates of depression. There are very few things as deadly as gender dysphoria, which also have proven medical treatments… yet still, while those treatments have been known, and FDA certified for over half a century, they are still are not covered by most insurers. Why are they not covered? Simple bias. Mostly innocent, but still bias. It seems most of the people who work in the insurance industry do not respect folks like me, who some day may wish to make their outie an innie. We are a side show attraction, and not people who should be helped, or cured by modern medicine, even if we are insured. “Only crazy people would want the surgery! But hey, we won’t cover their mental care either!!!”

To review, we are required to have a year of hormone therapy and a year of real life, full time experience. We are required to have TWO different therapists vouch for us, that we are trans enough and sane enough to make adult decisions about our body. Then, and only then, can we get the surgery. This is to prevent buyer’s remorse, and malpractice suits. Doctors want to know  someone is VERY serious about this very serious surgery, which comes with many risks including the likely loss of sexual sensation, and at least a six month recovery. But, post surgery trans folk have a lower suicide rate than the national average. It IS a cure. Let me know if I made that stat up. If I am wrong, I want to see the study. You know me, I post stats from memory, not from links, but I am not lying… and seldom mistaken.

People wonder why trans folk stand out so much in a crowd. One of the simplest reasons is: You only notice the ones that do. Another reason: Going full time is encouraged at a very early point in transition, in order to meet the requirements to get surgery ASAP, and let’s face it, most transitioners look extra funny early in transition. Things like breast augmentation surgery and facial feminization surgery are allowed, even pre-transition but it is suggested you wait 1-3 years, to better know what you will get from the hormones, before enhancing it. But hey, they want THE surgery? You know? That cosmetic surgery? The one nobody really gets to see after it is done except your doctor, significant other, and yourself… unless you are really bad at getting out of cars, whilst going commando?

So why would a vagina be helpful to a person like me? Well for starters, I would no longer be very good at peeing whilst standing. Actually that is not a good thing. Peeing is not the coolest thing in the world, but aiming is pretty neat. It can be a game. Paint the urinal yellow! I will miss that. Pretty good at that game by now. I win almost every time.

A real reason to get a vagina would be the ability to use bathrooms and dressing rooms without as much fear of persecution. Having the indoor plumbing would likely change my mindset, allowing me to feel more comfortable in such situations. If you don’t feel legit in a restroom, you do not tend to act normally. The restroom is something people should take for granted, so if a manly looking figure looks uncomfortable going into the women’s room, they will be likely to make others uncomfortable in the process. Making others uncomfortable makes me uncomfortable, creating an extremely uncomfortable feedback loop. I can not overestimate how big a deal the bathroom thing is. Using a bathroom with immunity is a right I feel like I lost the day I began transition. I literally have to live full time as a female for a year to even qualify for surgery, and that means I can not use the men’s room… period. No matter WHAT I look like. And I do not even know for sure that I want to have the surgery!?! I also don’t exactly enjoy being feminine ALL the time. I mean, I like it, but sometimes I want a break. It is a LOT of work being a new transitioner who is trying to find her amazingly awesome new place in society. Every thing I do or say requires more effort because I just’ve not exactly learned how yet to be comfortable in my own new and rapidly changing skin.

Did you know, a year of real life experience used to be required BEFORE hormone replacement therapy could be prescribed? This is still mostly the case in the UK.

So, transition is not for cosmetic reasons, but the insurance industry and medical community sure treat it like it is. I best get used to dresses and peeing whilst sitting. Remember, front to back. Front to back.

These twelve months are very much a rite of passage for trans folk, and honestly, as much as I am complaining in this post, I will likely look back fondly at this learning experience when I have come out the other side, just like the people who have come before me.

I do wonder, if kd lang (no caps), or Rachel Maddow would meet the standards for twelve months of full time, life experience, especially if it was based on their choices of attire alone.

Back to bathrooms, and then, I will get back to vaginas. I promise. Yay! Vaginas!!!

Currently, there are around nineteen states that cover trans equality. Elsewhere in the US of A, trans discrimination is allowed. I could be evicted, fired or even kicked out of an establishment simply for being in transition and it is legal in most states. Of those nineteen states, only two specifically mandate the legal use of restrooms that conform to my gender. Whenever trans rights come up, the bathroom issue goes front and center. What if a sexual predator dresses as a woman, and claims he is female, just so he can go into the women’s room and rape or otherwise abuse or molest women? That is always the argument. My rebuttal? Such a man would stand out like a sore thumb, much like I do, and people would notice him going into the establishment, and the restroom. He would also be easily caught. “It was the man in the dress!” I have to imagine there are easier and frankly, more effective ways to be a predator. This fear tactic assumes sexual predators have the mentality and nuance of Wile E. Coyote. In reality, if someone like me goes into a bathroom, it is because we need to use the bathroom. Also, it is a medical requirement in order to get a complete and cosmetic transition.

Back to vaginas. I promised. Why else would a vagina be helpful? Well, many trans women are triggered by their own genitals to the point of depression or even self mutilation. Personally, I would not be able to have my birth certificate changed without a vagina due to the current laws in the state where I was born. Why should that matter? Well, for starters any background check would reveal I am trans, even though that should not matter, whenever I am close to getting a job. Also, if the birth certificate changes, then legally, I am female, and females ARE covered by most all insurance policies for hormone treatments.

Here is something gross that most do not know about gender reassignment surgery. Before a person like me can get an innie, they have to have their hair permanently removed down there. That hair would continue to grow, inside. Ewwww. Right? So around a year’s worth of electrified needles must kill every single testicular and penile hair follicle before surgery would be allowed, and this hair removal is deemed, say it with me now, cosmetic.

Let’s review again, because I think I have painted the full picture I wished to paint. Transition is considered cosmetic and yet, the medical industry requires real life, full time experience and hormone treatment for at least a year, before they will allow further cosmetic treatments to take place. All this time, a trans woman would be required to use the women’s room, which is not a right protected by law in many places, and she would have to have her hair permanently and painfully removed from her junk before the surgery date, again, for cosmetic reasons. I guess it is cosmetic too. I mean, you gotta’ look good for your OBGYN. Yes, gynecological visits and mammograms will likely become part of my life. I already have to do self breast exams. It may or may not come as a surprise to you, but I have more trouble NOT examining my breasts than I do examining them.

Now for a slight non sequitur. The male and female anatomy are at their roots so similar, that once a penis is inverted, it will eventually be able to self lubricate. The more you know…

Funny, I have written all of this and I have not even got to the thing. The thing which inspired me to write this post in the first place. I promise, I will make this quick.

My insurance has lapsed.


Since Medicaid is now part of Obamacare, everyone was required to renew by a certain date and my wife and I never saw our renewal papers. Perhaps they were misplaced, I do not know. What I do know is I take my medical care and insurance seriously and I did not just sit around playing chicken with my free insurance. This renewal is a new thing. Used to be, at least in Hawaii, people would renew automatically, so it is probably a good thing to start with a clean slate. Many people are covered who do not live here anymore, or who are no longer alive, and their prescriptions and whatnot sometimes automatically renew, costing extra money that is not being well spent.

Now, I did get our insurance renewal submitted as soon as I got the notification that our insurance would innevitably lapse, but get this, it is going to take LONGER for the state to implement my renewal than they would have given me and my wife to fill out the renewal, had we received it in the first place. The fact is, I am now in line with practically every other person in Hawaii, because it seems that every person on Medicaid has had their policy lapse too, and they all lapsed at the same exact time! Like much of Obamacare, the policy is better on paper than the implementation… and it is hardly perfect on paper.

So, until this is fixed, no more therapy, no more anti-depressants, no more estrogen and no more testosterone blockers. I run out in a week. It may take two weeks before my insurance kicks back in. AND I can not say to my insurer, I need my hormones because I am transitioning, or they will not cover me at all. So the timer is ticking before I run out completely. I wonder, if that happens, would that invalidate my required twelve months of hormone replacement therapy, or real life experience?

Trans world problems indeed.



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