Moving Beyond Shock on Transgender Health

By Paul Schindler

Even for those with some knowledge of the economic, social, and health disparities facing the transgender community, an August New York Times Magazine story, “The High Price of Looking Like a Woman,”likely shocked the conscience.

The story explored an underground and little known practice by which so-called “pumpers” inject silicone into the breasts, buttocks, hips, and faces of transgender women aiming to feminize their appearance. The practice exists outside the medical care industry and without its safeguards –– or, usually, even anesthesia.

Among many medical risks associated with the practice is the customary use of loose silicone rather than enclosed implants, a procedure that can lead to the migration of silicone throughout the body and, in turn, disfigurement and scarring. The Times story, in gruesome detail, spelled out a host of other negative outcomes, including chronic infection, blood system poisoning, respiratory impairment, autoimmune reactions, pulmonary embolisms, and death.

The story cites a conclusion by the New York City health department that just over one-fifth of the estimated 12,500 transgender people in the city have undergone silicone injections. Given the high proportion of that population that is uninsured and the widespread exclusion of gender transition procedures in both private and public health care plans, it is likely that the vast majority of those silicone procedures were carried out in the unsafe underground pumping economy.

It’s all too easy to come away from the Times’ account with nothing more constructive than the view that these pumpers must be stopped. Although the story quotes a practitioner identified only as S. saying, “I try to help the girls because they want to look feminine,” advocates for the transgender community familiar with the phenomenon make clear that pumpers are culpable for the significant harm they cause.

Jillian Weiss, a legal scholar who teaches at New Jersey’s Ramapo College and works with corporations on transgender workplace diversity issues, told Gay City News, “The people who are doing this have to know the risks and are not informing those who come to them.”

Pauline Park, who heads up the New York Association for Gender Rights Advocacy (NYAGRA), said, “Pumpers prey on naïve trans people.”

Weiss and Park agree that pumpers should face criminal prosecution, but neither is under any illusion that going after the “supply” side will curb the unmet demand the transgender community has for procedures and hormone therapies needed to facilitate their gender transition.

Mara Keisling, the executive director of the National Center for Transgender Equality, emphasized that it is simplistic and demeaning to suggest that efforts by transgender women to feminize their appearance are all about cosmetics. In her view, feminizing is, above all else, about “passing” –– and not getting killed.

“It’s about survival in getting a job, about not getting beat up on the subway, or maybe about finding a guy who will let them have a bed for the night,” she said.

Weiss and Park emphasized that true liberation for transgender people likely involves self-acceptance on matters including appearance. But, to get from one day to the next usually forces other considerations. “I don’t feel that passing should be necessary for a transgender identity,” Weiss said, “but in the real world, it is.”

The goal, then, must be to expand private and public health insurance access to the full range of services transgender people need to lead full and productive lives –– including mental health counseling, hormone treatments, and surgical interventions, ranging from genital reconstruction to breast augmentation to facial feminization.

In most health insurance programs, that is a steep climb. Gender reassignment surgery, in particular, is widely disallowed.

Prohibitions and limitations on covering treatment related to gender transition –– even those that might be viewed as primarily “cosmetic” –– are based in prejudice. Breast augmentation is now viewed by society as a legitimate medical expense following a mastectomy, yet vital services are denied transgender people, despite the fact, as Keisling put it, that “science has rendered its judgment –– these are medically necessary.”

According to the Human Rights Campaign (HRC), Medicare does not cover gender reassignment surgery, though “there is no exclusion under the federal Medicaid statute.” As a result, the National Center for Lesbian Rights reports, “Almost every court that has ever considered the issue has concluded that states cannot categorically exclude sex reassignment surgeries for Medicaid coverage.”

Last month, for example, a three-judge federal court panel threw out a Wisconsin law banning hormone therapy or sex reassignment surgery for transsexual prison inmates. Cutting three transgender patients off from hormone treatment, the court found, amounted to “cruel and unusual punishment,” banned by the 8th Amendment to the US Constitution.

The 2005 Wisconsin statute that gave rise to the case, however, illustrates the political realities cutting against the posture federal courts have taken. When prison officials in the state first authorized hormone treatment for the three plaintiffs, a spate of news stories about taxpayer-funded “sex changes” led the Legislature to rush through a prohibition.

According to Park, NYAGRA, the Empire State Pride Agenda, and other groups have been working toward ending policies put in place during the Pataki administration that placed hurdles in the way of Medicaid funding for gender transition.

At the federal level, Park, Weiss, and Keisling all pointed to opportunities under the new health care law –– both in terms of banning discrimination based on gender identity/ expression in providing services and in defining the benefits available under expanded Medicaid eligibility and the health care exchanges the law establishes.

Discussions of these issues between advocates and staff at the Department of Health and Human Services have begun, but have not reached any definitive results. Keisling is upbeat about the possibilities: “The good thing about this administration is not that they do everything everyone wants, but that they are reasonable. We can go in, and if we show problems that can be fixed, I think we can get things done.”

Significant progress has made on comprehensive transgender health care at the nation’s largest corporate employees, due in good measure to pressure put on them by HRC through its Corporate Equality Index. According to the group, 25 percent of Fortune 100 and fully 40 percent of Fortune 1000 companies now offer transgender-inclusive health insurance. Speaking at the World Diversity Leadership Summit in Manhattan last week, Deena Fidas, deputy director of HRC’s Workplace Project, said corporate employees have found that such benefits do not materially increase their healthcare costs.

Many transgender Americans, of course, do not work for the nation’s largest employers. Some work at jobs where they get no health care benefits; others scrape by in the underground economy, including sex work. This situation is largely the legacy of pervasive discrimination. Only determined efforts at education and advocacy will change this picture.

As Keisling pointed out, “Young trans folks are often mentored. If a mentor says, ‘Go get silicone,” many will follow that advice.” Outreach to transgender youth, many of them invisible or living on the streets, is required.

But the bigger education challenge involves the broader society, and that demands that the larger gay and lesbian community join with our trans brothers and sisters in tearing down stereotypes about gender and demanding equal employment and healthcare access. As the LGBT community fights high profile battles like marriage equality, it cannot –– in good conscience –– forsake this critical responsibility.

This editorial first appeared on Gay City News.com on 14 September 2011.