“A year ago I showered in the dark.”
While this experience may seem unfamiliar to some, for many transgender people it is more than understandable. Turning off the light can be an easy adjustment if what you’re seeing might not agree with you. Chloe, author of the thoughtful article “A Weight Lifted,” thinks back to something as basic as daily hygiene as she reflects on how she lived before surgery that changed everything for her.
Although the phrase “top surgery” is used by many members of the trans community to describe various gender confirmation procedures, for Chloe and many others it means a double mastectomy, or removal of breast tissue, to achieve a flat-chested appearance. Surgery can be either inpatient or outpatient, and fluid drainage, suture care, and skin grafting are common features of a recovery process that can take several months.
Washington is a popular destination for those seeking top-notch surgery. People seeking breast reduction or removal for gender affirmation purposes may travel across the country—or even internationally—to have surgeries from household names like Dr. E. Antonio Mangubat, Tukwila surgeon of TikTok fame, or Dr. Javad Sajan from Seattle. whose methods often do without the notorious liquid drainage. However, the cost of the surgery itself — which costs anywhere from $8,000 to $15,000 out of pocket without insurance — costs many out of the procedure. That’s before accounting for travel and accommodation costs for those who have to travel long distances to reach their surgeons.
The UCLA Williams Institute estimated in 2019 that “1.4 million adults in the US identify as transgender [0.4 percent of the country’s population at the time]and about 152,000 of them are enrolled in Medicaid.” Washington is among the 17 states plus Washington, DC that specifically cover gender-affirming care under this program, and as follows: Apple Health paid for Chloe’s top surgery.
“The surgery was a dream. Everyone’s good vibes, ancestors, everything worked. And my surgery was free – 95, free – thanks – Obama!” said Chloë.
The weight removed from Chloe’s chest means similar relief for more Medicaid recipients seeking first-class surgery.
“I kept asking, ‘Are you sure? [it’s free]? That doesn’t sound right.” I was in denial until the day that – I’m still in denial. I’m still waiting for a check to be mailed!” They said.
The state ordinance on gender-affirming care is provided with a wealth of specifications. In addition to providing a diagnosis of gender dysphoria, the patient must provide a letter from a psychosocial doctor confirming the diagnosis in order for the procedure to be approved. Fortunately, both reductive and additive top surgeries do not have the mandatory second evaluation and 12 months of hormone therapy that other procedures require. However, the cost and accessibility of psychological validation can still present significant barriers for Medicaid recipients. Accessing top surgeries through Medicaid is a much longer process than filling out a simple form. It can be difficult enough for transgender people to find a therapist who affirms something so personal, let alone one who is affordable enough.
Working in the medical system
Chloe was struggling to access existing gender-affirming care offered by another medical company. When contacting the health insurance company by telephone, they were told that there were no specialists or support systems for their gender-affirming care. It was only when she interviewed other trans people that Chloe discovered that both of these programs existed and still exist today.
“I’ve never felt more drained than anyone else,” they said of their difficulties finding transgender healthcare at Kaiser. “I thought surgery would be the hard part, but I had to live with the gender dysphoria.”
Gender dysphoria can feel like a discrepancy between how you perceive your gender and how you perceive it, or a personal incompatibility with your own body. Gender dysphoria is frequently highlighted in approval papers and is a guiding factor in qualifying for trans health care under Medicaid.
The onset and persistence of the COVID-19 pandemic has made scheduling surgery times difficult. In addition to medical staff shortages and hospital systems being completely overwhelmed, the impact of long-distance COVID and hospital outbreaks is adding uncertainty to what are currently considered optional procedures.
Top operations are often misconstrued as voting procedures — “not necessary,” a term given extra weight by the pandemic crisis. As the pandemic hit, key surgeries were put on hold, leaving patients with an uncertain time frame for the procedure, sometimes after years of planning and preparation. The implications of this misclassification are tremendous for those seeking positive surgery and how trans healthcare is perceived overall.
Luckily, Chloe’s surgeon was on the ball.
“When Jay Inslee reinstated the rule against elective surgery … the plastic surgery bureau sent me a message that this could be a life-saving surgery,” they said.
Aftercare out of pocket
Recovery from top surgery is slow. It often starts with drains, rounds of painkillers, and occasional difficulty with everyday things like going to the bathroom. It progresses to restricted arm movement, skin grafts “revealing,” the removal of days-long binding, and a giddy smile at a flatter figure. The swelling subsides and the reach of the arms increases, but it takes months to be able to raise your arms overhead again.
Follow-up care isn’t covered by Medicaid: from gauze and aquaphor to mobility aids and physical therapy to ensure a steady out-of-pocket recovery, aside from managing follow-up appointments that can span several weeks.
“I just didn’t realize how much bandages, medical tape, Neosporin and how it all adds up. …The shelve [at the Bartell’s] is always empty every week,” Chloe said of her out-of-pocket follow-up. While the surgery itself is free through Medicaid — reducing most of the cost for many insureds — it still may not be enough. To take the final step, trans people turn to each other.
An indispensable operation
What categorizes as a “cosmetic” procedure is nothing short of a lifesaver for some people. Daily physical improvements after surgery include not wearing a binder, a garment that resembles an undershirt but constricts the chest to bind breast tissue and create a flatter appearance. When worn for long periods (according to many manufacturers, eight hours or more) or worn improperly, binders can cause discomfort, breathing difficulties and even broken ribs. People gain a greater range of motion when not wearing binding clothing. The discomfort caused by sweat and friction is relieved; With more lung capacity, belting out a favorite line in a song becomes a lot easier.
Emotionally, the relief is immense. A lot of conversations with trans people about gender revolve around dysphoria, but it’s time to add nuance to the conversation. There’s also gender euphoria, which is the sense of self-actualization that comes from experiencing your own gender in ways that counteract feelings of dysphoria. Some people find euphoria in their sex experiences without experiencing dysphoria, which doesn’t make them any less trans. Transaffirmative health laws must create avenues for those whose identities are shaped by signs of joy rather than alienation and discomfort.
Now that they’ve had top surgery, Chloe lives that euphoria on a daily basis. Dating is more accessible. Bathing spots in summer invite instead of ridicule. This important surgery, also marked by dysphoria and euphoria, continues to improve life and is offered on Medicaid.
“This summer is all the vibes,” said Chloe, a swimmer. “Boobs out, 2022!”
W. Barnett Marcus is a contributing writer for Real Change.