In July 2014, the settlement of a discrimination case against the state of Maryland resulted in a major shift in policy, requiring all state-provided health insurance to include access to coverage for gender transition health care, including surgeries. Little more than a year later, the number of patients seeking to align body, heart and mind is up, but there are still obstacles to overcome.
“Many health insurance plans sold in the country have boilerplate language that excludes trans-related health care,” says Patrick Paschall, executive director at FreeState Legal, a nonprofit that serves hundreds of clients per year; primarily LGBT people of color and low income clients. “In many cases [transgender patients] are able to access mental health care and hormone therapy, but in nearly all cases for which they seek surgery, those are almost universally denied.”
For those who have chosen surgery, Dr. Beverly Fischer, at Advanced Center for Plastic Surgery, a pioneer in gender reassignment (also called gender affirming) surgery, and her colleague Dr. Rachel Bluebond-Langner, assistant professor of surgery at the University of Maryland Medical Center, have been helping patients match feelings of gender identity with anatomy for years.
In 1996, when most transgender patients found it necessary to travel outside the U.S. for surgery, a colleague referred her patient to Fischer for “top surgery”—the term used for breast removal and transformation to a masculine chest in the case of female-to-male transgender patients, or breast augmentation for male-to-female patients—and Fischer took on the case.
“Two or three weeks after that, I started getting phone calls with people scheduling consultations,” recalls Fischer, “and I thought, ‘what is going on here?’”
Turns out, her patient was then president of the transgender society American Boyz, and he posted an article online (yes, way back in the mid-’90s Internet dark ages) stating his satisfaction and elation and directing others to his expert surgeon.
“I called him and said, you were my first patient I ever did!” she says.
For Fischer’s practice, the rest is history. Or, in some cases, herstory.
Upon consultation, Fischer, internationally respected for her work, takes time to get to know each patient and always asks when the realization struck that he or she was born with the wrong anatomy for how they felt inside.
“The stories of their struggles and what they’ve gone through—they’re very courageous,” she says. “I can’t imagine having to go through what a lot of them have gone through just to finally exist” in a body that aligns with their gender identity.”
To date, Fischer has performed upwards of 1,075 top surgeries, 98 percent of which are female to male and patients come from all over the U.S. and abroad. Requirements include a letter from a therapist that confirms diagnosed gender dysphoria, the clinical term used when a person does not mentally and emotionally gender-identify with their born anatomy. A patient must be 18-years-old but there are exceptions, in which case parental consent and multiple therapist diagnoses are needed. Often, but not always, the patient may also be required to take at least one year of hormones for the desired gender.
“I get so many letters of ‘you don’t know how you’ve changed my life,’” says Fischer. “I really feel like I’m making a difference in the world. [These patients] are so appreciative and fun to work with and they’ve taught me a lot.”
Earlier in her career, Fischer, a graduate of the combined Johns Hopkins University and University of Maryland Plastic and Reconstructive Surgery Program, says she was aware that colleagues spoke critically about her growing transgender surgery practice.
“I was sort of the persona non grata,” says Fischer, who also performs many other types of plastic surgery. They saw it as scandalous because “I had this great training and I was doing sex change surgery,” she explains. “Now they’re out there fighting for these cases because they’re so popular and now insurances are covering it. [Patients] are just coming in droves.”
Johns Hopkins was famously the first hospital to offer gender reassignment surgery starting in 1966. But the clinic later dissolved after Dr. John Money and plastic surgeon Milton Edgerton left. (Dr. Paul McHugh, who directed the medical school from 1975 to 2001, believes that surgery is not the solution.) Today Ph.D.s Kate Thomas and Chris Kraft run the Sexual Behaviors Consultation Clinic at Hopkins—they are leaders in their field.
Fischer sees about 200 patients per year—and approximately 20 of those see her for revisions of another surgeon’s work, often done like a straight-ahead mastectomy without any cosmetic attention to make the chest more masculine. With the insurance coverage change, Fischer expects the overall numbers to increase.
30-year-old Corbin Shansky underwent top surgery in November 2014, performed by Fischer, after about 5 months of hormone therapy, which, for him included estrogen suppressant and testosterone, to the tune of about $200 per month, more or less for life. He had robust health insurance through his former job and hormone therapy was covered (still an opaque area for insurance claims) but the surgery was not, because his federal government employer is not required to comply.
For many in the transgender community, hormones are a completely satisfying way to treat gender dysphoria. Some, says Shansky, even choose to take a very low dose of hormones so that they can maintain a more ambiguous appearance.
“That wasn’t me, I wanted everything to match,” he says. As a teen and young adult Shansky sexually identified as a lesbian, but something still didn’t feel right, and he gender-identified as male by about age 28.
“I’ve never wanted to have breasts,” says Shansky. “At first I was turned away from [surgery] because of scars, but I thought one day [scars] will have to do because I cannot stand them.”
As soon as Shansky made the decision to transition, he says he had “everything ready,” including work with a therapist, identifying an endocrinologist and beginning hormone therapy. After the surgery, which he paid for out of pocket, he left his employer and started a new job for the chance to start life anew.
“It feels pretty good, but it’s weird because [people now] see me as 100 percent born and raised a man,” he says. “Guys will start socializing with me in a way that I’ve not done before, and all the gross things that you [assume] men talk about in their little circles—well, it’s true,” he adds, with a laugh.
It’s a quandary, says Shansky.“I know what it feels like to be on the other end—and I’m not trying to out myself—but do I stand up and say ‘stop being a dick and respect women’ or do I just go along with it so I don’t get ostracized?”
Shansky plans to have bottom surgery as well. But he’s still employed by the feds, so he may end up paying out of pocket again. But, it was more important to get a fresh start than to look for an employer that offers the benefits.
For bottom surgery Fischer refers her clients to Bluebond-Langner at University of Maryland Medical Center, who, she says, “is going to be a superstar” and is also a graduate from the Hopkins/UMD plastic surgery program. She met Fischer during her residency rotation and was quickly drawn to working with the transgender community.
“Like with anything we do in plastic surgery, our goal is to restore form and function and to improve somebody’s quality of life,” says Bluebond-Langner. “And for transgender affirming surgery, that meets all of the goals of plastic surgery…the creative, functional and aesthetic aspects. You [work] all over the body. This makes it so rewarding.”
Bluebond-Langner performs top and bottom surgeries, one of which is the female-to-male procedure called phalloplasty. It uses tissue taken from another part of the body to create a functional and aesthetic penis.
The other procedure for female-to-male patients is called metoidoplasty, which Bluebond-Langner doesn’t currently perform. This option is available to patients after they have been on testosterone and the clitoris enlarges. The vagina is removed and the labia are used to construct a scrotum.
Then the urethra is lengthened “so you basically have a stump for a penis,” she explains. “It allows you to urinate standing, which is why a lot of men like it, but you can’t have penetrative sex with it.”
For male-to-female patients she offers vaginoplasty, which converts penile and scrotal tissues into a vagina, clitoris and labia. Some other services she provides are facial feminization and tracheal shave to reduce the appearance of an Adam’s apple.
For bottom surgeries, sexual function is retained, says Bluebond-Langner, and nerves are preserved so “there is tactile and erogenous sensation.”
“There’s more acceptance and understanding that this is a recognized diagnosis with clear treatment guidelines so more people are being identified and treated properly,” she says.
Transgender patients can receive specialized health care at Chase Brexton, a center for treatment and advocacy for the transgender community since 1978. They have six locations serving more than 29,000 patients and will open an LGBT Health Resource Center office at their Mount Vernon location this fall.
“With the new law passing for surgeries, it’s been an amazing improvement for the community,” says Deborah Dunn, a family practitioner physician assistant with Chase Brexton. “The public is more open and more accepting of this group now.”
In another example of growing acceptance, there are also evidence-based guidelines for transgender health care, distributed by the World Professional Association of Transgender Health (WPATH). But even with adjusted insurance laws and care guidelines, says Dunn, on the ground, there is still a ways to go.
“It’s important to find resources for people to feel comfortable and not mocked and laughed at,” she says, such as when a fully bearded person needs a pelvic sonogram because they have ovarian problems. “Where can they go?”
Doctors at emergency rooms and urgent care centers are “outwardly saying things like ‘we don’t know how to treat these things,’” she says. “So when [transgender patients] need medical treatment, they’d rather not go, and that’s probably one of the biggest barriers that we face in the transgender community.”
Little by little, insurance laws are changing to provide transgender patients coverage for continued care and, in some cases, making surgery more affordable. But for now, it can still mean thousands of dollars.
Shansky says that 13 months into his transition he’s spent more than $10,000, which includes counseling, endocrinology, medications, hormones, name and gender changes on official documents and new clothing and shoes because he’s become broader and cartilage expands so his feet grew, too. But the biggest bump by far is the surgery.
For self-pay top surgery, Fischer receives $8,600 (bottom surgery costs about ten times that amount). When the procedure is covered by insurance, she receives between $500 and $1,000 depending upon the provider.
“So there’s a big shift in my income but I do this surgery because I love it and I accept that’s what is going to happen,” she says. “I’m just happy that more people are able to have the surgery.”