Counselor explains the impact of federal benefits for gender dysphoria treatment
In late May, a US Department of Health and Human Services appeals board overturned a 1989 policy of automatically rejecting sex reassignment surgery benefits for trans people on Medicare. The appeals board ruled that sex reassignment surgery is a necessary and effective treatment for people who don’t identify with their biological sex, according to Healthfinder.gov, a website associated with the federal agency.
The change applies only to people on Medicare, the government medical insurance program for those who are at least 65 years old. It means that older trans people enrolled in the program can potentially get help paying for sex reassignment surgery if their doctor recommends that as the treatment option for gender dysphoria.
This new policy might not be as far-reaching as trans advocates might hope, but it’s a shift that has potential to effect change in other private and state insurance programs.
In June, for example, Massachusetts became the third state to provide Medicaid coverage for sex reassignment surgery.
Elaine Meizlish, a licensed social worker in Santa Fe at Counseling Within, has worked with the LGBT population for much of her career, beginning in Kansas City and then moving to Santa Fe in 2011. Meizlish works with both trans men and trans women clients, some of whom have chosen to use hormones, surgery or both to reflect the body characteristics commonly associated with their gender identity.
Whether they are transitioning or already living their lives as transgender, they face hurdles in navigating the medical and insurance realms.
“I see the medical treatment as being important to feeling congruent to who you are,” Meizlish says. “It helps deal with the gender dysphoria and body dysphoria that people have. In my experience with trans clients, they often hate the parts of their bodies that are not congruent with their gender identity.”
Medicare already covers hormone therapy for trans people under the Medicare Part D prescription drug plan formularies. Even there, trans people face barriers and confusion because of gender marker errors in computer-matching programs Medicare and insurers often use to prevent billing fraud.
“Dysphoria is very real,” Meizlish says. “What we see with dysphoria is the stress about how someone feels about themselves. It affects self-esteem, self-concept, anxiety and depression. Sometimes we see difficulty as secondary sexual characteristics are developing, hatred of your body, wishing you didn’t have the parts of your body that you biologically have.”
Sex reassignment surgery isn’t a necessary part of the transition process for many people who identify as trans, yet for those who do seek surgery, the potential of having it covered by Medicare can make it more accessible.
Some surgeries are more of an undertaking than others. For people who are transitioning from female to male, top surgery (such as a double mastectomy) might be a more feasible option than bottom surgery (genital reassignment surgery). For male to female transition, facial feminization, hair removal and bottom surgery are all options.
“I see some people feel more comfortable and have peace of mind when they just take hormones,” she says. “I’m also seeing more differentiation with my trans male clients. After a year or two of hormone therapy, they may want to do top surgery. And top surgery is certainly more accessible and less expensive than bottom surgery. It’s so individualized and it’s all part of the process. It’s not about surgery; it’s about feeling congruent for the person.”
Meizlish says over the time she has been in Santa Fe, she has seen more of an acceptance of trans people, especially compared to her practice in Kansas. But of course there is still significant progress to be made.
People who are trans still face high rates of violence, discrimin
ation, suicide and unemployment in our culture, especially trans women of color. These issues also need to be addressed.
Expanding health care coverage through Medicare benefits is a step in the right direction, but there are many more steps to be made to be inclusive and considerate of the experience lived by people who are trans.
This column was originally published in the Santa Fe Reporter.