Today I completed the US Trans Survey, a comprehensive study gathering information that will be used to inform public policy towards transgender people in the United States. Trans, genderqueer, and non-binary folks: if you haven’t taken the survey yet, please do so now! Our data is urgently needed.
On paper, my answers to the survey questions are encouraging. I have never been assaulted or harassed due to my gender identity. I have never been fired from a job or made to feel uncomfortable at work as a result of my trans status. I have had positive personal relationships, and I have not experienced homelessness. My answers, of course, are only a tiny fraction of the trans experience, but they are mostly good news. Unfortunately, they don’t quite tell the whole story. At the conclusion of the survey, participants are asked to share a personal story of either acceptance or discrimination to help round out the picture of their experiences. I’d like to share here a selection from what I wrote:
In many ways, I have been very fortunate as a trans man in the United States. I have a supportive immediate family, a wonderful fiancee, and a full-time job. However, although my salary is enough to support me, I am struck by the difficult choices I’ve had to make because of my trans status and my inability to get comprehensive transgender health care.
I began my medical transition four years ago with hormone therapy, but my health insurance has never paid for any of my trans-related treatment. Because I am fortunate enough to be employed, I have been able to pay for my hormones out of pocket, and I felt secure in the idea that I would be able to continue doing this indefinitely. However, I was recently shocked to learn that my usual, trans-friendly pharmacy has been barred from issuing my normal hormone prescription, and that the only replacement available would be twice the cost. Because of this capricious regulatory setback, I’ve been unable to get my regular medication, and this puts my health in a precarious and unexpected place, at least for the short term.
This short-term situation is frustrating and difficult, but it doesn’t even compare to the long-term anguish of having to choose between chest surgery and the normal life expenses of a young professional. Although I do have health insurance through my employer, all of the plans available to me specifically exclude coverage for any type of transgender care; thus, I would have to pay out of pocket for gender-affirming chest surgery, even though my doctor would affirm that such surgery is medically necessary for my health and well-being.
The practical upshot of these policies is that I must continually choose between my own health and well-being and my ability to afford the purchases and milestones that will contribute to my long-term livelihood and stability, and that will help me to contribute to my family and community. I am getting married next year, but I can’t possibly afford a wedding alongside a surgical procedure, so I’ve delayed my surgery. After the wedding, I’ll need a down payment for a house — there’s another delay. Once my housing is settled, perhaps I’ll want to raise children with my partner. Will I have to choose between top surgery and infant expenses? I’m sure that I’m not the only transgender millennial being held back by tough choices between medical care and participation in the so-called “American Dream.”
The refusal of American health insurance companies to cover transgender-related care — and the failure of our legislators to require them to do so — is a national embarrassment that could have far-reaching economic consequences. Just as housing, employment, and other forms of discrimination have created a wealth gap between white and non-white households, I have no doubt that the denial of comprehensive medical care for trans folks will likewise affect our incomes, stability, and earning power.
To force transgender people to choose between medical care and major life purchases is to hamstring the economic potential of an entire class of people in the United States. These discriminatory policies are hurting us as a nation in both moral and practical terms. Allies, please urge your legislators to step up and ensure that all insurance policies provide comprehensive health care for transgender people!
When you experience discrimination, it’s easy to feel like you’re alone. The very nature of discrimination is isolating: the minority is singled out for insults, ridicule, or poor treatment from the majority, and for transgender people, the numerical difference between majority and minority is huge. A 2011 study put the U.S. transgender population at an estimated 0.3 percent. Although a definitive count has never been performed, that estimate gives a sense of scale to trans people’s experiences as they fight for recognition and respect.
One of the most daunting and pervasive forums for anti-trans discrimination is the health care system. The landmark 2011 transgender discrimination study Injustice at Every Turn reported that 19% of trans people studied had been refused care due to their gender identity, 28% had postponed care due to discrimination, and a staggering 50% wound up educating their own doctors about trans issues. Yet it’s easy for individual trans patients to feel like they’re the only ones being treated this way.
Enter social media. The hashtag #transhealthfail was started by @MyTransHealth, an upcoming website that is building a database of transgender-friendly health professionals. (Their Kickstarter is here – and Philadelphia coverage is among their stretch goals!) The first tweets invited trans folks to share their negative experiences with healthcare providers, and the hashtag quickly exploded.
These posts reveal a daunting, often hostile environment for transgender patients. Some were misgendered, outed, or ridiculed in public:
#TransHealthFail “You’re the first ‘they’ person I’ve ever treated. I mean, I’ve had several young women come to me who use ‘he,’ but…”
— Klaus Thariaro (@KlausThariaro) August 6, 2015
Nurse:”When was your last period?” Me:”Never. I’m Transgender.” Nurse:”You really fooled me! I thought you were a woman.” #transhealthfail
— Julie Rei Goldstein (@JulieRei) July 30, 2015
Others were questioned or dismissed by doctors with narrow-minded or uneducated views of trans people:
Therapist: Are you bisexual, heterosexual, homosexual, or transsexual? Me: Wait, what? #transhealthfail
— Emily Prince (@emily_esque) July 30, 2015
And still others highlighted the serious failings of insurance coverage for transgender people in the U.S.:
Having to pay thousands of dollars since life saving surgeries for trans people are ‘cosmetic’ #transhealthfail
— noah (@_noah_og) August 6, 2015
#transhealthfail If I change my insurance gender marker to M, it’ll pay 4 HRT, but not reprod care. If I keep F, I have to pay for T myself
— Kieran (@QueeringPsych) August 6, 2015
The tweets go on – and to date, they show no sign of stopping. Although it’s terrible to see so many horror stories, the attention #transhealthfail is getting is encouraging. It is my hope that all of these tweets, shares, articles, and replies will spark support not only for political action – the passage of laws that ban discrimination and ensure health care access for all trans and non-binary people – but for transgender-specific training for health providers.
I got involved in healthcare training in 2013, just two years after I started my medical transition. I had previously spoken to college students and activists about transgender identities, but had never thought about addressing the medical community until I was asked to give a workshop at Good Shepherd Penn Partners, a physical rehab center in Philadelphia. They had recently served a transgender patient and were looking for ways to improve future care. I agreed, but the night before the presentation, I was getting nervous. Medical professionals go through years of school and training, I told myself. What could I tell these doctors and nurses that they didn’t already know?
It turned out that I had a lot to offer. The professionals I spoke with were all at the top of their field, yet many of them had never been trained in transgender issues. Every one of these doctors and nurses wanted to do their best for patients of all genders – they just didn’t have a lot of experience with the terminology, the range of identities, and the personal stories of trans people.
After the session, the organizer walked me to my car, and it was clear that the workshop had made a difference for her. “We just never talked about this back in medical school,” she explained to me. “I mean, for a lot of us, our training was ten or twenty years ago. They weren’t discussing these types of issues back then. Just having a vocabulary reference, knowing what to say and what not to – that’s huge!”
As I continued speaking at hospitals and clinics, I quickly realized the difference that a training session could make for both providers and patients. While there are certainly doctors who discriminate against trans patients out of bigotry and fear, I believe there are many more who want to be allies to the LGBTQ community – but they need the tools to do so.
We must champion comprehensive training and professional development for medical professionals – training that prepares them to treat transgender patients with compassion and respect. Of course, this training must start in medical school, but it must also extend beyond the classroom so that we can reach professionals who are already working in the field, and so that providers can keep up to date with best practices.
The best way to avoid a #transhealthfail is to teach our doctors, social workers, receptionists, nurses, security personnel, therapists, and everyone involved in patient care about transgender identities. This is not the job of the patient. It is the responsibility of the institution to seek out knowledge and to better serve the trans community.
Healthcare providers: Please step up and ensure that your staff have the knowledge they need to provide transgender patients with the highest standard of care. Let’s put the #transhealthfail hashtag out of commission for good.
A guy walked in on me today in the bathroom at work. It was entirely my own fault; I was sleepy, and I had forgotten to click the lock on the single-stall men’s room. He retreated at once, but I had to wonder what he saw.
At a glance, I’m sure I looked no different from any cisgender guy using a toilet. There’s nothing unusual (as I often remind myself) about a man sitting down in the loo — we all have to do it sometimes, right? I could have been any man at that moment, my shirttails rumpled from being tucked into my slacks, my boxers down around my knees, and my tie dangling as I hunched over my phone. My coworker surely didn’t look long enough to register any details. Yet in the sheepish aftermath, I kept wondering: Did he notice the sock?
Yes, there was a sock between my legs.
Let me explain. When I go to work or to certain more formal events, I wear a packer, which is basically a silicone penis. Some packers are functional and may be used as an STP (Stand To Pee) device, or sometimes for sex. My packer is entirely cosmetic. Its sole purpose is to provide a realistic bulge in my slacks.
(Here’s a bit of irony: after going to the trouble of finding and purchasing a realistic packer, one that even matches my skin tone, I wear my packer inside of a sock. This is for purely practical reasons. It’s a lot easier to throw a sock through the wash than it is to scrub silicone, and while I only own one packer, I have plenty of socks to switch out while one is being washed.)
My decision about whether or not to pack for a particular day is usually a question of wardrobe. Wearing a tie and khakis? Put on the packer. T-shirt and jeans? Packer stays home. This means that in general, I am packing 100% of the time at work, and close to nil in my personal life.
When I first started packing, it was because I had just started work as a college professor. I was in the early stages of my medical transition, and though my voice had dropped and my binder kept my chest reasonably flat, I couldn’t yet grow a beard or even male-signifying stubble. I was nervous about standing in front of a class as my not-quite-complete self. My job is to be watched; I have to capture and hold the attention of a group of late teens and early twenty-somethings, and when they’re seated at desks while I stand by the board, their eyes are naturally at crotch height. I didn’t want to risk questions — or worse, whispers — about what was not in my pants.
Yet in my everyday life, I never think about packing. Even when wearing relatively tight jeans, I never consider what people might think of my decidedly not-bulging anatomy. I know that some trans* men use packers to counteract dysphoria, that simply feeling the weight of it helps to ease the profound distress that many transgender people feel when they’re stuck in a body that doesn’t align with their gender identity. That’s not the case for me. I don’t feel any more or less like myself just by wearing a packer; I would never, for example, bother to wear it when I’m at home alone. So why do I feel the need to do it in public, and specifically on the job?
As I transition, my masculine gender expression is challenged much less frequently, and then I start to question the steps I take to reinforce my presentation as male. Some things, like wearing a beard or a tie, I do because I like them. I like the way that facial hair and men’s clothing make me look and feel, and the fact that they are such strong signifiers of masculine identity certainly doesn’t hurt. Other things, though, like wearing a packer and a chest binder, have no intrinsic value to me. These extra bits of wardrobe are uncomfortable and inconvenient; I wear them not because I want to, but because I feel like I have to.
As I thought more about my trans* wardrobe this year, I realized that switching back and forth — wearing a packer to work, then taking it off when I go home and go out with friends — represents a kind of physical code-switching. I alter the dialect of my gender expression depending on the “listeners” around me and how comfortable I feel with them. This is especially evident with my chest binder. I wear it whenever I leave the house for any significant period of time, no matter who I’m with, but if friends come over to visit, they’ll know we’re close if I excuse myself to go change out of my binder and into a baggy shirt.
When I realized how much I was allowing other people’s perceptions to dictate what I wore and how comfortable I was, I felt immediately rebellious. After all, I told myself, what does it matter what students think of my crotch? They probably don’t notice anything. And aren’t there plenty of cisgender men with bigger chests than mine who walk around every day, unchallenged and unperturbed?
I made up my mind: I was going to stop wearing a packer to work. It was silly, I told myself, and was evidence of nothing but my own insecurities. I wasn’t yet ready to give up on the chest binder, but the packer seemed like a good place to start.
On the same day that I steeled my resolve, I met up with a friend and colleague, a fellow transgender male college professor. We were discussing “teaching while trans,” and he told me the story of a time when he had disclosed his identity to a group of students. Most of the students had been respectful, he explained, but one was visibly shocked, so much that she fell out of her chair. She looked up at him and burst out,
“So that’s why there’s nothing in your pants!”
The story had a positive ending — the student kept taking courses with my colleague, and eventually told him how that disclosure had inspired her — but it also shattered my newly-formed resolution. How could I put aside my packer when I was now absolutely convinced that everyone was staring at my crotch?
That’s how it came to pass that this morning, at work, I was sitting on the can with a silicone penis, wrapped in a sock, dangling from an elastic strap around my waist.
The guy who walked in on me probably never saw the sock, and even if he had, it’s unlikely that he would connect the dots and realize that I am transgender. Yet the very fact that I was wearing a packer made me feel much less self-conscious about that embarrassing restroom moment.
I continue to wear a packer in my professional life because it acts as my armor of expectations. When I’m at home or with friends, I can feel very comfortable subverting expectations, especially gendered ones — but at work, I tend to save my fighting spirit for other things. I’d rather challenge students’ ideas about the materials they’re reading than upend their mental graphs correlating “manhood” with “observed penis.”
Sometimes I think that this makes me a coward. In a perfect world, maybe I would toss out my packer, and my chest binder too, and champion a fluid kind of masculinity. But then, in a perfect world, I’d be able to continue my medical transition to my preferred endpoint and render both packer and binder obsolete.
I often think of being transgender as living a compromise. My body doesn’t align with my gender identity; that’s a fact I have to live with. My transition is about making choices that let me express who I am, even imperfectly, and to do that I often switch the language of my gender expression according to who I’m with and what I’m trying to communicate. So for now, I’ll keep packing — it’s just another part of my gender code.