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A Transgender Perspective
Chloe Schwenke, Ph.D.
The health insurance needs of transgender people can differ substantially from those of gay and lesbian persons, especially when such “trans” people are FSOs or partners/spouses of FSOs. I’m neither – I am a consultant who frequently works for USAID and other bilateral and multilateral donors, but my wife and I have been abroad for extended periods on major USAID contracts. But I am getting ahead of myself – there are so many complicating factors when a transgender person considers health insurance options and constraints in the context of an overseas assignment, or even generally as a roleplayer in international affairs or international relief and development. Let’s unpack this a little, starting by telling something of my own story.
Typical to nearly all transgender persons, the decision to transition – to change gender, or more accurately to bring your body gender into alignment with your mind and spirit gender – is something that can be deferred or denied for only so long. The need for integrity, for authenticity and wholeness, grows in an aggregate way; a time comes when the decision must be made. This raises the first health care challenge for trans people – how to get access to properly trained, caring mental health professionals. While many posts in developed and post-industrial countries have specialized transgender therapists, almost no posts in developing or transitional countries do. Those mental health professionals who do exist in such locations are likely to be hostile to or ignorant of the transgender phenomenon. I faced just this challenge as a Fulbright professor based in Uganda in 2005-6. There wasn’t anyone to turn to in Uganda, or even throughout East Africa, for professional help, for me, or for my wife and children (significant others of transgender people have their own critical needs for separate therapeutic support). The nearest specialists were in Europe or South Africa, well out of reach of a Fulbright stipend. I made it through the year, and spent some of this time doing my own web-based research on gender transitions, but there was no substitute for receiving professional counseling. When my family and I did return to our home in Maryland, we found that there were several excellent transgender therapists in the metropolitan Washington DC area – but we also found that our Blue Cross insurance policy explicitly excluded any medical or mental health services associated with transgender treatment. That exclusion clause exists in all major health policies, except for private sector firms or institutions who take a proactive stance by insisting that their insurers include the needs of transgender persons.
Once I was able to work through the complicated, exacting, but clarifying diagnostic part of transgender therapy, I was clear in my mind and spirit that the time to transition had come. I sensed the enormous strains that this transition would impose on my wife and children, my extended family and friends, my faith community, and my employer, but despite all of those weighty factors, the decision to transition was clearly one of fundamental survival. There really wasn’t a choice. My wife and children too faced enormous adjustments, requiring caring support, but through this care we remain a strong, unified, and loving family.
Beyond therapy, a number of health interventions arise in the transition of one’s gender. Often this starts with hormone treatment, which presents enormous health risks if not carried out under the supervision of a competent endocrinologist. I had considered starting on this regimen while in Uganda, only to find out that there were not any endocrinologists in all of East Africa. For someone at a foreign post in a developing country, this may mean a trip home or to the nearest more developed country to undergo the blood tests, health screening, and consultations necessary to start and to then monitor these treatments. Potentially, a local general medical practitioner who is supportive of such an intervention would be found in a less developed country – perhaps even at the medical facility at an Embassy – but only to serve in a monitoring capacity. The need to begin and be in the ultimate care of an endocrinologist is very important. Again, however, these expensive specialized services are not covered by any of the usual health insurance policies. There are, however, several excellent endocrinologists in the Washington DC area.
Unlike sexual orientation, there really isn’t any way to be discreet about changing one’s gender. A critically important part of the therapeutic process is living and dressing in the gender you know yourself to be. My therapist asked me early on to come to our sessions dressed as a female, which necessitated awkward changes of clothing in my car in the dark corners of underground parking lots. At least once I was dressed and with make up on, I passed pretty easily as a female. Not all transgender people do “pass” easily, yet their needs to express their authentic gender are every bit as urgent and valid as my own. In less tolerant societies than those found in liberal cities in the east and western regions of the United States, the humiliation experienced by transitioning people who appear in public, or need to use public toilet facilities, while not easily “passing”, presents profound problems, or the potential for serious victimization by others, even (in countries such as Uganda where I lived) by the government authorities. Few if any foreign diplomatic or aid missions are geared up to understand or be supportive in such situations, and the more realistic option may be to request a transfer back to Washington for the two to three years that most transitions require. Even for those who do not easily “pass”, once well enough into their transition they take on an air of confidence and poise that more than compensates for their challenging physiques. Still, there will be the need for certain medical interventions: voice therapy and laser facial hair removal/electrolysis for male-to-female transgender persons, and breast reduction surgery for many female-to-male trans folk are essential. Depending on the person, other costly treatments may also be needed: facial feminization surgery, breast augmentation, or hair transplants. These terribly expensive procedures are “cosmetic” only in a technical sense; the ability to be accepted in your authentic gender by society and those you care about the most is central to your mental and spiritual well-being. Of course none of these interventions are covered by health insurance, and most of these procedures are completely unavailable in most developing countries. Conceivably, many of these interventions could be carried out during visits back home, as usually only ordinary medical supervision is needed afterwards, if at all.
Many transgender people, such as I, decide that sexual reassignment surgery (SRS) is appropriate and necessary to achieve the wholeness and peace that we have so long been denied. Other trans people do not take this route – the decision is entirely personal, and the state of one’s genitals is hardly the concern of others. Still, for those who do decide upon SRS, the costs are extremely high, and the time for recuperation and the many therapeutic interventions needed afterwards are not insignificant. These procedures join the long list of excluded costs under insurance schemes, despite the now well-established consensus among the professional medical community that the transgender phenomenon is a neurobiological and not psychotic condition. In other words, being transgender is a legitimate medical condition – but there are so few transgender persons that we lack the advocacy weight to force insurance companies to extend their coverage to our needed treatments. For male-to-female SRS alone, the costs are usually between $17,000 to $25,000. For female-to-male SRS, the costs can easily be three times as high or higher. For my entire transition, the costs exceeded $50,000.
SRS cannot be undertaken until one has lived “real life experience” in one’s authentic gender for at least one full year, 100% of the time. Candidates for this procedure usually must be under a therapist’s supervision, and they will need to undergo an expensive (and, of course, not covered by insurance) assessment by a psychiatrist before being allowed to have this surgery. There are half a dozen or more well-established surgeons in North America who carry out SRS, with waiting lists of six months or longer. Conceivably, a transitioning person at a foreign post could live full time in their authentic gender and be supervised by a transgender therapist over long-distance calls or Skype while waiting for SRS, but the assessment by the psychiatrist would require being physically present with an appropriately trained and receptive specialist.
There are many resources available to transitioning persons in the Washington metropolitan area. I list below the ones who I have personal experience with and high regard for, but there are others. I would encourage anyone who is seeking such services to ask around – there are now many transgender groups on-line, and getting advice from other trans persons is always advisable. Even here in Washington, there are many specialists who are transphobic.
My list of recommended service providers includes the following:
- voice therapy: Tish Moody, 308 Inspiration Lane, The Kentlands, Maryland 20878, tel 301-840-1215
- electrologist: Mona, Hair Free Electrolysis, 7315 Wisconsin Avenue, Suite 110E, Bethesda, MD 20814, tel. 301-986-4986
- endocrinologist: Dr. Michael Dempsey, 3200 Tower Oaks Boulevard, Suite 250, Rockville, MD 20852, tel. 301-770-7373
- transgender therapist: Martha Harris, LCSW, 2820 School Street, Alexandria, VA 22303, tel. 703-717-0999
- SRS surgeon: Dr. Pierre Brassard, GRS MTL, 995 De Salaberry, Montréal, Québec H3L 1L2, Canada, tel. (514) 288-2097 / fax (514) 288-3547, firstname.lastname@example.org
The only other important consideration for transgender persons based abroad is to reach out to others. This is a complicated journey, and perhaps one of life’s greatest endeavors. To succeed, you will need support and understanding. Embassies and aid missions need to be made aware of the transgender phenomenon; a simple investment of 3 hours of diversity training can significantly improve the receptivity and sensitivity of the daily work environment for trans people. Connecting with other transgender people is also essential. Every society has transgender people, although some societies are so transphobic that these people live under deep cover, or suffer profound victimization. Transgender people and support groups are accessible on-line, and of course there are now excellent books on the subject (try starting with She’s Not There, by Jennifer Boylan).
GLIFAA is both sensitive and committed to the needs of transgender persons, and remains an excellent resource. There is so much work ahead to do, particularly in changing insurance exclusionary clauses, and in raising awareness of the transgender phenomenon, but there has never been a better time for transgender persons than now.