An earlier version of this article identified a source by both first and last name. The article has since been updated to help protect that source’s identity. (Updated Feb. 1, 2021)
Río L. just wanted a doctor who understood.
Río is a transmasculine person who, for much of 2020, was trying to have a gender affirming procedure called top surgery, where the breast tissue of the chest is removed.
“When COVID-19 canceled all my plans for 2020, I realized I had a unique opportunity and window of time to attempt to pursue top surgery,” said Río, a Virginia resident. “I fought to get it covered by insurance, which was a challenge.”
Río, who uses they/them pronouns, said medical professionals often misunderstand their experience and often misgendered them. They also met resistance from insurance companies, which didn’t consider their surgery “medically necessary”.
They finally were approved for surgery, but only after hours spent on the phone. Río concedes many people don’t have the time to dedicate to navigating the insurance process, not to mention the additional hurdles posed by pandemic, like delays to elective procedures and the need to self isolate before and after.
“I have the time to devote to hours of phone calls with insurance and health care providers, time off work, and ability to self-isolate to stay Covid negative,” Río said in an email interview. “It seems like it would be really difficult to navigate this process with less resources.”
Río’s challenges to accessing gender affirming health care are not unique. According to the Human Rights Campaign, almost a quarter of the transgender community has been refused medical care because of their identity and over 20% of transgender individuals live without healthcare.
Experts and activists say that the pandemic has further exacerbated these trends.
Barriers to care
As with other surgical procedures, physicians must first approve a patient for the procedure and file for insurance approval. Gender affirming procedures, like Río’s, are usually categorized as elective by insurance companies.
On the onset of the COVID-19 pandemic, many hospitals canceled elective procedures in an effort to mitigate the spread of the disease within their facilities. Additionally, many physicians transitioned their services online.
Whitman-Walker Health has been offering gender affirming healthcare in Washington, D.C., since the 1970s, but since the pandemic, they’ve been unable to offer most of their in-person services and are instead relying on telehealth calls.
Britt Walsh, director of Gender Affirming Care at Whitman-Walker, said that because coronavirus cases are increasing nationally, most health care personnel at the clinic are having to work remotely to meet patients’ needs.
“While we know that there’s some people who can’t access a video visit, we can have phone visits so we make sure we don’t leave anyone behind,” Walsh said.
After receiving a physician’s approval, the patient must then seek coverage through their insurance provider. Every insurance company is different, but overall, insurance coverage of a procedure is granted for a year’s time frame. Should a surgery be delayed, paperwork must be resubmitted for approval for the next year.
That means transgender people who received coverage for their gender affirming procedures during 2020 only for it to be delayed will likely have to resubmit paperwork to receive procedure coverage for 2021.
Taylor Richman is a transgender woman living in the Savannah, Georgia, area who is nearly a year into receiving gender affirming therapies.
While she said the COVID-19 pandemic hasn’t directly complicated her receiving treatments, finding insurance as a trans person has been challenging.
“I’m a Type 1 diabetic, so I’m trying to find insurance that will help me with my diabetes but at the same time help me go down the course I want to go down,” Richman said.
Richman said she’s still looking for an insurance company that fits her healthcare needs, so she’s currently seeing a doctor outside of insurance for her hormone therapies.
Out 2 Enroll is one national organization helping LGBTQ individuals like Richman find the right health insurance for their needs under the Affordable Care Act.
Katie Keith, leader of the organization, said because so many insurance companies don’t see top and bottom surgeries as critically important healthcare, many transgender individuals have to fight to receive the care that they need.
“If your insurance company denies something, you should appeal, appeal, appeal, is what we tell people,” Keith said. “It’s a real pain in the ass, but oftentimes things are reversed if you appeal.”
Keith admitted the pandemic has shed light on not just the insurance gaps within the community but also the importance of insurance during a national health crisis.
“I think a lot of folks have found it even more challenging than normal to get the coverage that they need, especially if they were already having trouble getting coverage before now,” Keith said.
Organizations around the country have been attempting to meet the increased health care needs within the transgender community.
Eugene, Oregon-based Point of Pride offers both in-person and online resouces for transgender individuals nationwide, like surgical financial assistance, hormone therapies and shapewear shipment.
However, Jeff Main, secretary of the nonprofit’s board of directors, said its volunteers were unable to work at the center.
“For a few months we had to suspend shipments altogether, and only recently were we able to mail again,” Main said. “This means that our recipients are without access to these gender affirming resources and are far more likely to, unfortunately, rely on unsafe binding techniques.”
Point of Pride began accepting applications for its 2021 Annual Trans Surgery Fund, which helps cover the costs of gender-affirming surgeries for many transgender people whose savings for surgeries have been impacted by the pandemic.
“We expect the pandemic to have lasting effects on trans folks as they struggle to rebuild and afford care, particularly when it comes to access to surgery,” he said.
Job discrimination fosters more challenges
According to the Human Rights Campaign and PSB Research studies, 17% of LGBTQ individuals lost their jobs because of the pandemic as compared to 13% of their heterosexual peers.
Many transgender Americans are not protected from discrimination in the work place, which increases their likelihood for unemployment. It can also increase their chances of becoming a victim of transphobic violence, addiction and homelessness, according to the National Center for Transgender Equality.
And according to the National Transgender Discrimination Survey, transgender women of color had the highest rate of sex trade participation, followed by Latinx transgender individuals. These two populations are chronically underserved, but D.C. organization Helping Individual Prostitutes Survive, or HIPS, offers resources to local sex workers, such as shelter, a clothing closet and health care services.
David Sternberg, HIPS clinical manager, said the pandemic forced the group to close its shelter with showers, laundry and community gathering spaces.
“It really was once a hopping place, but there was no way to use those spaces safely with social distancing so we did have to close that center,” Sternberg said. “We’ve been able to open it in small ways throughout the pandemic, but we don’t have the traffic anymore.”
Despite the temporary closure, he said many of the group’s services have been able to continue uninterrupted as they were already virtual or mobile or have been converted to such.
But as the pandemic continues, healthcare and employment inequities will continue to widen, which could force thousands of transgender people like Río and Richman to go without critical healthcare that suits their individual needs as well as protections that safeguard them from discrimination, according to the National Gay and Lesbian Task Force and the National Center for Transgender Equality.
“The pandemic made this whole process both easier and more difficult,” Río said. Easier because of more time to recover from surgery. And more difficult because “less ability to see my closest friends,” they said.
“And much concern over possible delays due to COVID.”