The hurdles and hardships of being trans in America
By Theresa Diffendal
Imagine if you needed a letter from your therapist signing off on your mental stability before you could receive a prescription.
For about one in every 300 people in United States, that scenario is a reality.
Trans individuals are those who do not identify with the gender they were assigned at birth. Often times trans individuals will take hormones, a process called Hormone Replacement Therapy (HRT), or undergo surgery to help their bodies physically present as the gender with which they identify.
However, trans people often have to jump through a myriad of hoops before they can begin receiving these treatments, treatments which Mazzoni Center Senior Communications Manger Elisabeth Flynn said help to counteract “things like depression, anxiety, rejection by family and society…[which] stem from the difficulty of being trans or gender nonconforming in a society where being different in any way can be hard.”
Emmet Binkowski, a 22-year-old senior at Bryn Mawr College, has been taking testosterone since October 2014. Binkowski goes to the Mazzoni Center to receive health care. The Mazzoni Center is non-profit health care center located in the heart of Philadelphia, the city of brotherly love. It is unique in that in specializes in healthcare for members of the LGBT+ community – lesbians, gays, bisexuals, trans, and other gender identity and sexual orientation minorities.
To be given a prescription for hormones, trans individuals often have to get cleared by a therapist before they can begin HRT or undergo gender reassignment surgery.
“You have to go and talk to a social worker basically,” Binkowski explained. “Some places just a regular endocrinologist will prescribe you hormones if you have a letter from a therapist that you’ve been seeing and talking to about your transition. There’s gatekeeping that goes on where you have to have this official letter.”
That’s one visit. “Then you also have to get bloodwork done to make sure there’s nothing physiological that would make it harmful for you to start hormones,” Binkowski said. For example, testosterone can make already high blood pressure worse.
“Then they show you how to do the injection. Then you can just do them yourself every week. They teach you to do it in the fat instead of the muscle because it hurts less,” he added. “Sometimes it feels like nothing at all, sometimes it stings, but it’s no big deal after you’ve done it every week for a year.”
But just getting to a health care center can be a struggle. The time period between coming out as trans and starting HRT was extended “because it was just difficult to get into the city and go all the way to Mazzoni and come back. It takes hours by the time you go there, do whatever you need to do, and come back.
The most helpful time at the Mazzoni Center for Binkowski and other youths is during walk-in hours on Wednesday nights from 5-7.
“Last year we had 623 visits to youth drop-in,” Flynn said. “The majority of these youth have less than 12th grade education, are homeless or unstably housed. Most of the youth who attend drop-in are at less than 100% of the federal poverty level, and most are racial or ethnic minorities.
“We definitely do get some college youth and other LGBT identified young people who have heard about us and may be insured but they may want to access care in a place that is specifically LGBT-focused, is not their ‘family’ provider, or where people don’t necessarily know them,” Flynn said. “But the majority of our youth clients are coming to us because they don’t have another place to receive care.”
Money doesn’t grow on trees
Then there’s the cost. The Philadelphia Center for Transgender Surgery prices for male-to-female and female-to-male genital, chest, and facial reassignment surgery can amount to over $140,000 and $124,000 respectively.
HRT costs about $45-55 a month, depending on the brand and type of hormone, and that’s before trips to the doctor for regular check-ups.
“After you start you have to get a checkup at three months, six months, and then a year,” Binkowski, who takes testosterone – T – explained. “They take your bloodwork because the goal of taking the hormones is to get your testosterone levels up to what they would be in a cis guy your age basically. If it’s too low it won’t have as much of an effect but if it’s too high then your body actually starts converting it back into estrogen which is counter-productive.”
Binkowski self-administers a shot once a week and will likely continue doing so for the rest of his life.
“It’s essentially signing up to take it for the rest of your life if you want the effects to stay the same,” he said. “The voice drop is permanent and whatever body hair you’d grown up to that point would stay. You would start getting periods again unless you had a hysterectomy. But if you stop taking T then it goes back to how it was before.”
Yet trans people are one of the least likely demographics to have that amount of money as they face high rates of workplace discrimination.
A survey conducted by the National Center for Transgender Equality found that trans individuals are twice as likely to be unemployed compared to the general population. Additionally, 90% of those surveyed reported experiencing “harassment, mistreatment or discrimination” on the job, forty-seven percent said they had been fired, not hired or denied a promotion, and over one-quarter reported that they had lost a job, all because they identified as trans.
But trans individuals often lack the legal ability to fight discrimination. Only about half the states have non-discrimination laws that protect individuals against employment discrimination based on gender identity.
No job means a lack of a steady income and often no insurance, which ultimately means an inability for trans individuals to acquire the treatment and care they need to exist as they identify.
The insurance problem
That extraordinary sum for treatment must usually be paid entirely by the individuals as it can be difficult to find health insurance that covers treatment, which many view as cosmetic as opposed to medically necessary.
“The way the system works, right now you can be diagnosed with gender identity disorder or gender dysphoria, their medical term for being trans,” Binkowski said. “And it can be helpful to have that diagnosis because then you can tell a doctor ‘look I have this diagnosis which means I need this medical treatment.’ But it can be damaging if that’s not how you conceive of your experiences. It’s still medicalizing something that’s created by society. The problem is that this isn’t normative in society and it’s stigmatized and the problem is not my identity and desire to transition.”
By medicalizing the rhetoric, doctors turn trans identity into a mental condition, furthering the problematic idea that being trans is a mental disorder instead of an identity.
Even though the problematic wording exists, insurance is often necessary if trans individuals want treatment.
The Affordable Care Act (ACA), popularly known as Obamacare, “has definitely had a positive impact for LGBT people, in expanding access to insurance for many folks who otherwise could not get covered,” Flynn said. At the Mazzoni Center, “the number of patients we see who are uninsured was about 40% back in 2012, and last year it was 31%.”
But ACA doesn’t stop at providing insurance. “Some of the most significant changes are the legal requirements tied up with the ACA, for example the law prohibits sex discrimination in hospitals and other health programs or facilities receiving federal financial assistance,” Flynn said. “Many courts and the Department of Health and Human Services have interpreted the law to prohibit discrimination against people who are transgender or who fail to conform to gender stereotypes.”
As a marker of how many businesses provide healthcare for trans individuals, the Corporate Equality Index, which is published annually by the Human Rights Campaign Foundation, rates United States workplaces “on corporate policies and practices pertinent to lesbian, gay, bisexual and transgender employees.”
Companies that earn 100 percent, or the top score, on the Corporate Equality Index are acknowledged as meeting conditions outlined by the Human Rights Campaign meant to promote LGBT+ equality.
In 2009 the Human Rights Campaign Foundation altered its criteria so that earning 100 percent on the Corporate Equality Index “would require employers to offer at least one firm-wide available health insurance plan that covers medically necessary transition-related care, including gender confirming surgeries.”
In addition, one of the policies outlined on the index is “gender transition guidelines with supportive restroom, dress code and documentation guidance,” all implementations which create a safe and inclusive environment for trans individuals as they undergo transition.
In the Human Rights Campaign Foundation’s 2016 index, its most recent, a record-breaking 407 businesses scored 100 percent, implying that healthcare accessibility for trans individuals is on the rise. And yet, of all Fortune 500 companies, “Transgender-Inclusive Benefits” are only offered by forty percent.
Quality of care
While access to healthcare for trans individuals may be on the rise, an increasing problem is that the supply of healthcare, and often its quality, is unable to meet the demand.
“Many [trans individuals] are finding that very few doctors are actually trained and prepared to treat them,” Flynn said. “There’s still a great gap in terms of provider training and what we call ‘cultural competence’ – providers who fully understand the concept of gender identity, and whose practices are well versed in using the kind of language that demonstrates respect for and understanding of trans people, know how to ask what pronouns to use, etc.”
In these scenarios, the patients are must teach their care provider about their condition. While this ignorance is at best a nuisance, it can be harmful and become outright deadly if the providers are unable to meet the needs of their patients.
Binkowski, who came out as trans at 19, saw a therapist in Texas during the beginning of his coming out process.
\“[The therapist] had no experience at all working with any queer people,” he said. “When I explained to him that I was trans I had to explain to him gender and biological sex…very basic explanation of what a trans person even is. He said ‘okay I’ve heard of that, but I don’t really know how to talk about it at all.’ He had no idea.”
Binkowski’s experience is far from unique. “The reality is that many trans people have had horrible experiences, ranging from disrespect to outright discrimination, even abuse, at the hands of their healthcare system in the past,” Flynn added. “This kind of experience makes many people wary of engaging with healthcare providers, and this – what I would call lack of access to knowledgeable, culturally competent providers, in addition to the many economic barriers trans people face – are the two greatest challenges in terms of overall access to care.”
Hope in the Form of the Mazzoni Center
For trans individuals like Binkowski, the Mazzoni Center has been a beacon of hope in an obstacle-ridden field.
“I first went to the Mazzoni Center when I was a sophomore [at Bryn Mawr], so fall 2013. I was actually asking for referrals to trans friendly therapists,” he said.
The Mazzoni Center is the only practice in Philadelphia that specifically caters to the needs of the LGBT+ community. According to their website, they have provided care to over 2,500 trans individuals since 2000.
“We went from 284 new trans patients at our medical practice in 2012, to seeing 534 new trans patients in 2015,” Flynn said. She believes the rising number of trans patients is “due to greater awareness about gender identity, more people coming to the realization that they were, in fact, trans or gender nonconforming, and deciding that they wanted to pursue some form of social and/or medical transition. “
At Mazzoni, informed consent is the law of the land. Whereas other centers may require a letter from a therapist before an individual can begin treatment, “we believe that an individual is the best determiner of their own identity and medical needs,” Flynn explained. “It means that we work very closely with a person to educate them on the medical options and best practices that are relevant to their situation, and help determine what is the right path for them.”
The Mazzoni Center actively works to improve health care resources for trans individuals throughout the nation with events like the annual Philadelphia Trans Health Conference. The conference allows the Mazzoni Center to “offer workshops and trainings and networking opportunities for medical, legal and social service providers who want to become more competent in working with trans patients and clients, or want to share their experiences and best practices with others who work in the field,” Flynn said.
The center is looking to expand in 2017 to be able to better meet the needs of the LGBT+ community in Philadelphia. “We are eager to be in a place where we can better meet those needs and allow people to access multiple health and wellness needs under one roof,” Flynn said.
For Binkowski and hundreds more in the LGBT+ community, the Mazzoni Center provides one-of-a-kind practices that allow individuals to not only survive but thrive. News of its success and necessity can only spread, and hopefully the obstacles facing trans individuals who need to receive health care but are unable, and with it the stigmatization of trans people, will become a thing of the past.