On the morning of November 8, I assuaged my Election Day anxieties by working on a small grant application that a mentor had suggested she could put in front of some friendly funders. For months I had been developing a project examining how US institutions are responding to a growing demand for transgender (or trans-) healthcare. On a recent research trip to a surgical workshop I had secured buy-in for the project from surgeons in influential medical schools and from a major international trans- healthcare advocacy organization. I was optimistic as I sent off my application. But by the time I went to bed that night, things had changed. A few days later my mentor sent me an email. “Do you think you need to change anything about how you frame this given the uncertainties of the Affordable Care Act and civil rights for trans people?” she asked. Yeah. It looks like I’ll need to change everything.
Though no one can be certain what policy changes will come with the new DJT administration, signs are not good. Nascent legal protections for trans- Americans are especially vulnerable. Nearly all of Trump’s cabinet nominees have expressed anti LGBT sentiment. Uncertainty and pessimism about tenuous legal protections for trans- people have led to spikes in requests for identity document changes, with community groups across the country holding information sessions to help guide folks through this often labyrinthine process, and fund raisers to help cover the costs of court and document fees. Already there have been suggestions that new policies that allow trans- people to serve openly in the military will be rolled back. And few believe that a new US Attorney will pursue laws that allow trans- Americans to use restrooms in accord with their gender identity.
So with these basic civil rights under attack, what does the future of American trans- medicine look like?
Despite stories of social progress that clinicians often offer for why they’ve been motivated to increase services to trans- Americans, its likely not surprising to learn that expanded insurance coverage has been a significant motivator in recent years. When the Center for Medicare Services (CMS) overturned their 1981 exclusion of “transsexual” surgery in 2014, the possibility of covering previously excluded procedures became a reality. Ten states now expressly forbid discrimination against trans- people in Medicaid programs. The expansion of public and private health insurance doesn’t only open the possibility of services to those who could not otherwise afford them; it also establishes guaranteed funds that support the establishment of new programs, expertise, and clinical training. The absence of these funds is a significant reason why very few comprehensive trans- medicine programs exist in the US.
In the summer of 2016, the Affordable Care Act forbade discrimination on the basis of gender identity in any facility receiving federal funding. And by the fall of 2016 I was in the cramped basement of a Midwestern hospital where 20 surgeons from around the US were dissecting cadavers in an effort to learn the specialized procedures for trans- genital reconstruction that haven’t been taught in American medical schools for decades. One plastic surgeon from the West Coast told me about the intense competition in his region for the establishment of this specialty. University hospitals, county hospitals, and private clinics were all trying to stake a claim, he said. “I don’t want to say its all about money, but….” A young surgeon from New England explained why he was participating in the workshop, “My hospital said, There’s money on the table. Go get the money. We’re not going to give you anything, but go get the money.”
With ACA on the chopping block and the dismissal of trans- medicine as illegitimate, few are optimistic that the dozen universities across the country who sent surgeons to the workshop would continue growing their programs if funding was to disappear. And it will likely disappear before it has really materialized. On New Year’s Eve, a federal judge blocked provisions of the ACA that would have prevented discrimination of healthcare provision based on gender identity. Maybe, an optimistic friend suggested, the participating surgeons were interested in learning these procedures because the procedures are interesting. That is undoubtedly so. But the procedures have always been interesting; they haven’t always been covered.
No money on the table, no patients either.
Cutbacks and reductions of services have already begun. The Veterans Health Administration had been an early leader in plans to provide surgical services for trans- vets. They announced a week after the election that budgetary constraints would delay the rollout of those services, despite a commissioned report that estimated the maximum annual cost of providing transition related care amounted to just “.013 percent of the VHA’s $153.8 billion budget.”
A psychiatric nurse practitioner who frequently evaluates trans- folks seeking surgical services told me that she’s seen a surge in requests for surgery letters since the election. Her clients, she explained, are worried that the new administration will roll back state and federal coverage for hormone therapy and surgical procedures. The small number of American surgeons who specialize in trans- specific procedures have had years-long waiting list for decades, and recent expansions of insurance coverage without the expansion of clinical capacity have compounded those waiting lists. Hopeful and prospective patients are racing the clock before the incoming administration resets policies back to the 1980s.
As a group that has only recently entered the mainstream American consciousness, trans- people are feeling the strain and scorn of a new political moment in which care for them has been derided from the right as misguided and conciliatory, and from the left as the bridge-too-far that undid progressive politics. The question that my mentor asked about the concerns of trans- civil rights is an apt one. But since trans- rights have so often been articulated in the form of claims to and for medical care, my work on institutional capacities for trans- healthcare might stay closer to the legal issue than her first read of my grant proposal suggested. Like everyone, I’ll have to wait and watch.
Eric Plemons is an Assistant Professor of Anthropology at the University of Arizona and a core faculty member in its Transgender Studies Initiative. His forthcoming book, The Look of a Woman (2017, Duke University Press), examines Facial Feminization Surgery, a series of bone and soft tissue reconstructive surgeries intended to feminize the faces of male-to-female trans- women.