I woke up on Wednesday to a text from a friend in Canada. “Let me know if you need to stay somewhere,” he wrote. “You are a Jewish trans man in Trump’s America. You may need to run.”
Transition was going to be something I approached gradually. “I’m tiptoeing into manhood like a cold ocean,” I wrote in my first “How to Be a Guy” column. But Trump’s election has butchered my gently sloping beach, and left an unforgiving cliff in its place.
I came out publicly a year this month. November 2, 2015: I know, because it was the Monday after Halloween. I was going to take this November — and this column — to catch my breath, to take a look at where I’ve come from and where I’m headed.
Instead, the question of how to be a guy has suddenly gone from social to brutally practical. I’m making lists. Packing bags. Trying to figure out how much it’s going to cost to get a new passport, a new name. Thinking about passability in worst-case scenarios.
“Get all of your paperwork in order before January,” websites and e-mails advise me. “Change the gender marker on your license, your passport, your birth certificate. Find a way to stock up on hormones. Try to schedule surgery.”
The cliff is high. The water is forbidding. And everything I’m carrying — every relationship, every priority, every preference — suddenly feels like a line tangled around my legs.
I don’t really talk about medical transition in public. There are two reasons for that: First of all, it’s nobody’s goddamn business but my doctor’s; second, it’s a subject that’s only grown more painful and more delicate for me.
See, I have health insurance through my husband’s job. (I recognize that this makes me lucky as hell compared to a lot of my peers; the fact that we live in a country where access to basic medical care is treated as a privilege and not a right is a whole other conversation.) My insurance covers most of the cost of asthma medication and auto-injectable epinepherine. It pays 70 percent of the cost of an out-of-network therapist. The knowledge that seeking medical care in emergencies won’t throw me into crippling debt has saved my life more than once.
But. But.
My insurance does not cover transition.
Not only does my insurance not cover transition, but it specifically excludes coverage of “Care, services or treatment for non-congenital transsexualism, gender dysphoria or sexual reassignment or change.”
This is all perfectly legal. Yes, I live in Oregon, which bans insurance companies from discriminating against transgender clients. Yes, the Affordable Care Act has similar guidelines.
But here’s what no one tells you when we celebrate the progress we’ve made on healthcare reform: Those state and ACA guidelines only apply to insurance companies. Businesses who self-insure through brokers — businesses like the one where my husband works — are regulated by the Employee Retirement Income Security Act, ERISA. And ERISA doesn’t mandate coverage. ERISA doesn’t even recognize gender dysphoria.
Think for a minute about what that means. There’s the obvious stuff (hormones, surgery) but there’s also the fact that, if my therapist codes gender dysphoria into my statements, I lose my mental health care. Officially, he sees me for generalized anxiety disorder and depression.
There’s the fact that I need a doctor’s letter — and an official diagnosis — to change the gender marker on my driver’s license.
You see where this is going, right?
A year and a half ago, I started having unusually heavy and frequent periods. There was maybe a week in any given month when I wasn’t bleeding. I was miserable and anemic, not to mention spending a king’s ransom on tampons.
Testosterone would stop or significantly slow my period. A hysterectomy definitely would. Both are standard gender-confirming treatments; both are covered under my insurance for a bevy of other conditions. Know what my insurance will cover for me?
Progesterone and estrogen.
I take a lot of iron supplements.
I came out publicly just over a year ago, and the last year has included some fairly vivid windows into the precise value of my life.
“We’ll have to look into the cost,” my husband’s bosses said, when he first approached them about the possibility of adding coverage, or at least relaxing an exclusion clause so draconian the ACLU lawyer we consulted said he hadn’t seen anything so bad in a decade. It would be unfair, they told him, if people’s premiums went up for something that affected such a small minority of employees.
My husband came to them with facts and figures. He came with policy suggestions and offers of expert consultants willing to work pro bono, and personal pleas, and the goodwill of his decade working there, and the seven years I spent at the same company before going freelance. And they listened, and nodded, and were very sympathetic, and said they’d have to consult with their financial advisers.
“There isn’t enough data,” the financial advisers told them. “It’s not worth it.”
And in the end, they said no.
(Well. Technically, they said not yet. Maybe next year. They’ll think about it. But there are, of course, bigger fish to fry.)
It’s one thing knowing in theory how little people around you value your life.
It’s another entirely to have it confirmed en masse: to have your country vote in an administration that wants your dignity and self-determination stripped away, men who believe that the best way to deal with people like you is to lock them up, subject them to electroshock therapy. Who encourage their supporters to bring guns into the bathroom, just in case.
What do I do? I have a surgeon’s letter. Thanks to significant help from my parents, I was able to get top surgery out of pocket and out of network, but I can’t pass as a man without hormones. I get stares no matter which bathroom I use.
What do I do? I can get an M on my driver’s license, but anywhere that letter is likely to matter, the disparity between it and my inability to pass will put me at more risk, not less.
What do I do? I can change my name and get a new passport, but there’s a decent chance that changing my legal gender will be the end of my access to any health care. Every one of my trans friends has this story: denial of coverage for anatomy-appropriate healthcare because of the M or F on their files, serious conditions ignored or refused because of the possibility that they might in some way be tied to transition, or because a doctor or insurance company assumed anyone confused enough to be experiencing gender dysphoria couldn’t be trusted to accurately report symptoms. It’s such a common experience that there’s even a term for it: Trans Broken Arm Syndrome.
The things transpeople do when we don’t have access to transition care cause a whole other set of problems. Holding it because you feel unsafe using the bathroom? That’s one way to get kidney stones. Binding for 10 to 12 hours a day? Don’t break a rib — and cross your fingers that you don’t have any preexisting respiratory issues.
I catch myself doing terrible math: If I have to choose between my gender and my asthma meds, which do I let drop? Where does the quality-of-life tradeoff become intolerable?
And those are just the things we do to ourselves. Never mind the risks we take — especially transfeminine people — if we dare to be visibly gender-nonconforming. The jobs we lose. The assaults.
(Would my insurance cover me if I were assaulted for being visibly transgender, or would that automatically place related claims under the exclusion clause? I wonder. They won’t tell me unless I file a claim.)
What the hell do I do?
I’m preparing to jump, as best I can. If there’s one thing this has taught me, it’s that I can survive anything if I can find some way to get through it on my own terms.
I guess it’s time to pick a middle name.
