Healthy transitions

Trans people are struggling to find decent health care -- but hope is in sight

HAVOQ/Pride at Work protests Kaiser at the 2012 Pride Parade.

When the Human Rights Campaign, the national LGBT rights group, released its latest scorecard, rating companies by their support for LGBT issues, the healthcare giant Kaiser scored 100 percent. In June, the company's float in the San Francisco Pride Parade was packed with happy employees.

But as the float passed through the streets, it was met by a group of protesters. Pride at Work complained, loudly, that Kaiser — for all its efforts to work with the community — excludes transgender care from its standard policies.

"We said, let's push Kaiser," said Sasha Wright, an organizer with Pride at Work. "They say they're good for the community. Let's show them that the queer community demands this."

It was a perfect sign of the city's struggle with trans health care. In many ways, San Francisco is exemplary — this is a long ways from Chattanooga, Texas, where state legislator Richard Floyd tried to pass a law instituting steep fines for people who can't prove their genders match the designated genders of public bathrooms.

And with Healthy San Francisco officials' recent decision to cover transgender and care, it's likely this city is leading the nation in trans health.

But that's a limited distinction — because trans people everywhere, even here, still face sometimes daunting obstacles in getting access even to basic care. And the struggle to change that is becoming a high-profile (and increasingly successful) political fight.


Kaiser's insurance plans are typical of the industry. In its 2012-2013 "Traditional Plan," Kaiser lists "transgender surgeries" among the services excluded from coverage, along with massage therapy and cosmetic surgery.

And Kaiser's not alone.

Medicare, the federal health plan for low-income people, specifically excludes transgender health care. MediCal, the state version, is required to cover trans care — but will often deny individual applications. And many of the doctors and surgeons who accept MediCal (and many don't) are unfamiliar with transition-related care.

Then there's plain old discrimination. A troubling number of people report being denied healthcare — not just healthcare related to their gender identity — because the doctor they saw didn't want to treat a transgender person.

The State of Transgender California, a 2008 survey by the Transgender Law Center, found that 30 percent of transgender people in California reported that they have "postponed care for illness or preventative care due to disrespect and discrimination from doctors or other healthcare providers. Over 40 percent did so because of economic barriers."

The study also found that 35 percent of respondents "recount having to teach their doctor or care provider about transgender people in order to get appropriate care."

To make things worse, American health insurance is overwhelmingly employer-based — and unemployment among trans people is epidemic. A 2011 study from the National Center for Transgender Equality found that trans unemployment was double the national rate and that 47 percent of trans people surveyed had been fired or overlooked for a job.

The World Professional Association for Transgender Health (WPATH) sets the international standard for transgender health care. WPATH states that, for many transgender people, "sex reassignment surgery is effective and medically necessary." Hormone therapy, voice and communication therapy, as well as non-discriminatory primary and preventative care are also necessary.

But with high rates of poverty and discrimination among transgender people, affording these medically necessary procedures can be nearly impossible. Even in San Francisco, where some politicians and powerful organizations advocate tirelessly for transgender rights, many people are forced to go outside the system altogether to take care of themselves.

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