Note: This is a rough transcript of episode 24 of Health Savings News and has been lightly edited for clarity. It may not be in its final form.
Hello and welcome to Health Savings News, the podcast about healthcare costs in America and how to save money on the often expensive care all kinds of people need. I’m your host, Evan O’Connor, joined by retired doctors Rich Sagall and Mike Woods. Each episode we discuss healthcare costs in America, offer tips for saving money, and relevant news that affects and reflects the expensive landscape of healthcare in America.
This week’s topic is gender affirming care. This episode is coming out just before LGBT Health Awareness Week, and we wanted to invite someone onto the podcast talk more about the cost of this essential care, as well as the cost of not being able to access it. We’d like to welcome to the podcast a licensed mental health counselor — and my brother — Micah O’Connor. Thanks for joining us, Micah.
Happy to be here.
To start, we’ll define some of the terms we’ll be using as they may be new to some listeners. Gender affirming care is any healthcare that affirms a person’s gender. In the context of transgender people, it often refers to transitioning; but cisgender people, those who identify as their gender assigned at birth, also access gender affirming care in the form of treating erectile dysfunction, hair transplants, breast augmentation or reconstruction after breast cancer, or reduction, or any other healthcare — including mental healthcare — that validates the patient’s experience of their gender. Gender identity is one’s innermost concept of self as male female. A blend of both commonly referred to as gender fluid, or neither, often referred to as non-binary. This is different from a sexual preference, which is an inherent enduring emotional, romantic, or sexual attraction to other people. A person’s sexual orientation is independent of their gender identity. Gender expression is how people present their physical appearance of their gender identity usually expressed through behavior, clothing, body characteristics or voice in which may or may not conform to socially defined behaviors and characteristics typically associated with being either masculine or feminine. Gender transition is a process by which trans people strive to more closely align their gender identity with their external appearance. Some people may socially transition whereby they may dress differently, use chosen names and pronouns, or be socially recognized as another gender. Some people undergo physical transitions in which they modify their bodies through medical interventions.
Can you help us define the difference between gender dysphoria and gender euphoria?
Yeah, for sure. So the American Psychiatric Association defines gender dysphoria as a psychological distress that might result from an incongruence between one’s sex assigned at birth and one’s gender identity. You know, for as many people there are in the world, there is the same number of ways for one to feel about their gender or to express one’s gender. Every person is different. So when it comes to gender dysphoria, some people might describe this as feeling born in the wrong body, and they might describe this as feeling disconnected from their body or disconnected from their gender, or not feeling seen by others for who they really are. And then, you know, some folks might explain gender dysphoria in a completely different way. When it comes to gender euphoria is by definition the opposite of dysphoria, right? So it is having one’s body or one’s presentation feel aligned with one’s perception of their gender. So people might often describe gender euphoria as like being embodied in their body, feeling like others perceive them as the gender that they identify with. And the way I usually like to explain gender euphoria to folks is that it is like looking in the mirror for the first time and having this moment of like, “oh, there you are.” And then, you know, some folks might explain their gender euphoria in a completely different way.
Can you walk us through some of the processes involved with gender transition? Why don’t we start with your area of expertise, which is the mental health aspects of helping somebody with a gender transition.
Yeah. So I’m a licensed mental health counselor. So I do a lot of supporting folks around the emotional aspects of their gender transition. You know, when it comes to transitioning one’s gender, it looks — again — looks different for every person. Some folks might choose to only transition socially, so that would be around using like a different name, different pronouns than they were assigned at birth, wearing different clothing moving through the world in a way that better aligns with the gender they identify with. So as a licensed mental health counselor, it’s my role to support folks in exploring, you know, what parts of transition feel good for them, whether that be like just using the social piece and how to emotionally support folks as they’re trying to navigate that in a new way or assert the boundaries with the people that they care about in terms of perceiving them in their gender affirmation.
Also, through mental health services, there is some support around the medical transition for folks. When it comes to medical transition, some folks might choose to engage in gender affirming hormone therapy. So either taking testosterone or estrogen or testosterone blockers depending on how folks are trying to navigate their gender affirmation. Folks might also engage in the seeking of gender affirming surgeries. Gender affirming surgeries, augment genitals, chest face, body to better reflect their gender. Or folks might also engage in gender affirming vocal support. So working with a speech pathologist or a vocal coach to have a vocal resonance, a vocal tone that better affirms who they are as a person.
Again, although these pieces are very medical in nature, there is a lot of mental health support that’s often required due to insurance requirements for these processes. So oftentimes insurances require letters in support of gender affirming surgeries from mental health providers in order to obtain gender affirming surgeries. And depending on where you live, depending on the state, sometimes insurances also require it, or providers sometimes require it for engaging in gender affirming hormone therapies or accessing other medical interventions.
And then again, the last piece for transition for folks is sometimes folks seek to transition legally as well, and that can look like changing their name legally, updating their gender marker on documents such as social security cards, driver’s licenses, passports, birth certificates, et cetera. And again, depending on where you live, depending on the state, there are different requirements in terms of the support that is needed to change gender markers. Certain states just allow you to attest yourself that this is who you are, provide your legal name change, provide what you want your gender marker to be, and your state will allow you to change that. Other states need documentation, whether that be from surgeons or mental health professionals or other doctors supporting your desire to change your gender marker on your legal documents.
So as a mental health provider, what are some of the common mental health diagnoses that you see associated with people who are having gender dysphoria?
That’s a great question. So in terms of like mental health diagnoses, the term gender dysphoria is a diagnosis in itself. I think it’s really important though to clarify that like being transgender is not a mental illness as seen by the American Psychiatric Association, nor is gender dysphoria technically a mental illness, but simply a word we use to describe psychological distress. And it is a diagnosis that we utilize in order to bill for services such as like therapy or such as gender affirming hormones or gender affirming procedures. Separate from gender dysphoria though, folks who are seeking mental health support as being a transgender person often come in with concerns around depression, anxiety, adjustment disorders. And these, again, are usually the results of often like gender dysphoria as well as like how folks are treated by society as a transgender person and the minority stress associated with being a transgender person.
Do you find that counseling is usually adequate or are there some situations where you might receive some medical treatment? I’m specifically referring to like, you know, depression and anxiety that are commonly treated medically. Do you find that some of the patients actually will benefit from this type of medication?
Yeah, you know, transgender folks are folks, right? They’re just like everybody else where, you know, therapy can be really helpful for individuals and outside of therapy, that medication can be helpful for them as well. And that’s definitely something whenever I’m meeting with somebody, I always encourage them to consider and to like collaborate with a doctor. The reality too is that for a lot of transgender folks, much like cisgender folks, they exist with anxiety and depression outside of their gender identity. And so depending on who it is, depending on what’s going on, it definitely can be something that is helpful for folks.
One of the questions that a lot of people ask, I guess is, you know, how soon can someone identify as a different gender from their, when they’re born? And I’m assuming there’s a gap between when people start to suspect and when they actually realize what their gender identity is. So what are some of the, you know, average ages that you might see those transitions?
So it really is a spectrum. And, you know, as we develop as a society and understand like transness as a concept, it is shifting all the time, right? So the data shows us that folks can start to identify as a gender other than that they were assigned at birth as early as speech develops. So like as early as three or four, right? That children have an understanding of what gender is and that the gender they align with might not be what people are telling them their gender is. That being said, most folks in the society don’t live in communities or in families where we have conversations about gender, and that one’s gender can be different than that’s assigned at birth. And so oftentimes folks come to the understanding when they understand that concept exists. And so we often see folks, you know, especially when they’re starting to develop secondary sex characteristics or like development of breasts or menstruation or deepening of voice, that they start to actually really feel dysphoria. And so oftentimes folks have that understanding in early adolescence, late adolescence, and then folks also come to that understanding even later in life, right? So there are lots of folks who are in their thirties, forties, fifties, sixties, seventies, you know, throughout the lifespan where they’re starting to understand their gender differently.
What are some of the short and long-term benefits from gender affirming care for those who get it?
So the benefits are vast. You know, most of them are mental health oriented, right? So folks who desire gender affirming medical care or gender affirming social transition or legal transition, the data shows us that those folks have drastic and significant reductions in anxiety, in depression, in suicidality, in substance use. The data right now is saying that approximately 82% of people who identify as transgender contemplate suicide at some point in their lives, and over 40% of those people attempt suicide. And through research, we have found that by engaging in medical transition, if that’s something somebody is desiring, those rates plummet. And so living is a real and important long-term benefit of engaging in medical care, if that’s what you desire. But also folks just also report, you know, increased confidence, increased satisfaction in social relationships, and romantic relationships, basically pervasively through their lives see improvement. And that can be as short as 12 months, and then that can be throughout the lifespan as well.
One of the things that we had as a reason we wanted to sort of highlight this topic is that there’s a lot of controversy surrounding transgender care. And from our perspective of physicians, a lot of it is not as controversial as you would think, because from our research we’ve discovered that there is a lot of scientific evidence to support some of the things that are done for folks with transgender issues. The other aspect of that is, you know, just how difficult it is for children under the age of 18 to access the type of services they need. And what are some of the, the barriers that you see to that and, you know, what’s your read on the scientific evidence for some of the treatments?
Well, there’s lots of barriers to accessing gender affirming care, right? A big one is cost, right? There are many insurances throughout this country who help fund gender affirming care in different ways, whether that be through gender affirming hormone therapies or gender affirming surgeries. Some insurances, though, don’t cover those things. And depending, even if you are in a state that encourages insurance to cover gender affirming medical intervention, there are some insurances that have self-pay contracts that don’t have to. And oftentimes insurances require prior authorizations or a lot of like work for trans folks in order to obtain the care that they need, even if they can get it covered. So there’s that cost piece, there’s that high barrier piece. Along with that, there are oftentimes, depending on where you live, huge care gaps of providers who are able to prescribe gender affirming hormones or perform gender affirming surgeries,
Or I assume willing to.
That is the other big piece, correct, Mike, right? Who are willing to, right? You know, there are certain states where a primary care provider can provide gender affirming hormone therapies, and then there are certain states where you have to go to an endocrinologist or a reproductive health specialist in order to obtain these things. So basic access is a huge piece. And then this other piece that you’re mentioning around legislation is becoming a bigger and bigger issue. You know, there are many states in this country — I think last I checked about 26 states — have current legislation that is being discussed and argued that are looking to limit gender affirming care or a transgender people’s ability to exist in society at different levels, whether that be making it impossible for minors to access gender affirming care, whether that be preventing adults from accessing gender affirming care, or preventing insurances from covering gender affirming care, making it more difficult for adults to access, or making it qualified as child abuse for children to be engaged in gender affirming care, or for a parent to be engaging in gender affirming care. So these are huge barriers for folks to accessing care that, you know, the data shows us is medically necessary. And I think that was the last piece of your question, Mike, right? Like, what is the science saying?
Yeah, I mean, I, I’ve, I’ve seen some information about how politicians frequently get some of the information wrong. And a lot of the politicians seem to be up in arms about gender affirming surgery in children, which from what I understand is never done; that the only treatment that children may get is puberty blockers to prevent the onset of secondary sexual changes which increase the gender dysphoria, so…
Yeah, exactly right. There is this large false narrative that often goes around this country that if children are engaging in gender affirming care, that we are performing major medical surgeries on minors. And the reality is that most children who are expressing gender incongruence often engage in social transition, right? So they use a different name, they use different pronouns, their parents will go out and buy them clothes that feel good on their bodies, and they will move through the world as the gender that they identify with. As children reach a prepubescent area, families may choose to work with their doctors or work with specialists, moreover specialists to introduce like puberty blockers, which would temporarily arrest the development of puberty and secondary sex characteristics. And the benefit of these for kids is often that it gives kids time to think and to process and work with mental health professionals, work with medical professionals, work with their families on deciding next steps without the, the increased pressure of the development of secondary sex characteristics, like you said, Mike, which can increase dysphoria for folks. Children at that time again, can work with their medical professionals, work with their families to create a plan, which oftentimes can look like tapering off puberty blockers and titrating onto gender affirming hormone therapies, which would happen in later adolescents to, you know, mimic what would be considered like quote unquote “normative biological puberty.” And the benefits for these children who do engage in this is that through a more normative puberty, there’s often less development of secondary sex characteristics that aren’t desired, which actually leads to less need for intervention through things like surgeries. So, you know, trans-masculine like adolescents don’t require top surgery. Folks don’t grow into a normative height for their gender they’re assigned. And the reality is too, is that these children often can move through the world a little bit more safely cuz they quote unquote “pass” better as like a cisgender person, you know? But even then, folks who don’t obtain gender affirming care in adolescents also benefit from gender affirming hormones later in life as well. And you are completely right, Mike, that kids aren’t getting surgeries, especially young children aren’t getting surgeries. On the rare occasion older adolescents, so usually teenagers, 15 and older who’ve already developed secondary sex characteristics might have like a gender affirming top surgery. So like a double mastectomy. But, again, this is the same age that we often allow children who have developed larger breasts engage in like breast reductions. And sometimes that children might even engage in like breast augmentation to have larger breasts, right? These things happen before children turn 18. But the reality is, is that no insurance covers gender affirming surgeries under the age 18. So the rarity of the children, or older adolescents who obtain gender affirming surgeries between the ages of 15 and 18 are often self-paid.
Let me point out, as a pediatrician, puberty blockers aren’t new or unique to transgender. They’ve been a standard therapy for a long, a long time before these puberty blockers were developed. This was years ago when I was a young pediatrician. We would have kids come in that were having puberty as early as, you know, six or seven years old, which is a terribly upsetting thing to a very young child. And puberty blockers would develop for that reason to, to help these children who were developing puberty much earlier than their peers to fit in better by slowing down the puberty process and allowing them to be more consistent with their peers. So the puberty broker is not a new technology, it was not developed specifically for transgender individuals. It’s really been a very well accepted and beneficial therapy for many children who had entered premature puberty.
Yeah, exactly. There’s a lot of narrative around the country that a lot of these medical interventions such as puberty blockers, such as gender affirming hormones, such as surgeries are new or that there’s not enough data around them. And for the most part, there is decades worth of data showing that they’re safe and efficient and that kids and people live like healthier, happier lives when they choose to engage in them.
You talk about misconceptions as to what, what is happening in this area and the types of procedures that are done and who they’ve done on. Do you find that that’s a big problem?
It’s a massive problem. We’re seeing it right now across the country, right? That these misconceptions are leading folks to creating laws that are broad in scope and aren’t just limiting, you know, 10 year olds from getting a gender affirming surgery. They’re limiting children and families and adults from making collaborative decisions with their medical providers that could create relief and help support them in leading a happier and healthier life. So it’s a massive problem and there’s a lot of miseducation. And that perpetuated discourse not only prevents access, but also creates distress in folks. You know, to be a trans person in this world, having to listen to complete strangers argue about the validity of your life and the necessary-ness of your ability to access healthcare is part of what perpetuates depression in trans folks. It’s dehumanizing. And who wouldn’t feel anxious about that?
Yeah, especially since I’ve seen some laws that are actually may be term deciding that addressing a a child in the clothes of an opposite gender can also be considered child abuse. So some of the laws are actually potentially going that far in preventing gender affirming care.
It’s also interesting that the people who want government out of their lives and less government are the ones who wanna interfere and tell me what they should be doing.
Yes. I recently heard a conservative official report that “the government should be so small that you should barely know it exists.” And I think there are a lot of women and trans folks who aren’t there who would argue that it very much exists for them and due to conservative legislation.
Yeah. There are currently over 300 anti-transgender bills that have introduced just in the first few months of 2023, dozens of harmful op-eds published in leading national news publications and calls to quote “eradicate transgenderism” at right wing political events. All of this contributes to the likelihood of violence against transgender people, especially trans women of color, and increases the risk of self harm and suicide among transgender youth, as you’ve been saying.
What are some of the health issues that providers should be aware of when they’re dealing with trans patients?
Yeah, for example, I’ve read that cervical cancer screening for transgender men and mammograms for transgender women are often overlooked. So I agree with Rich’s question as, are other medical issues that are often overlooked in the transgender population?
Yeah, you know, I think it’s important to note, right, that these medical issues being overlooked are due to several factors. One of which is that many transgender folks in medical settings often feel judged or have to experience microaggressions from medical professionals who are not knowledgeable about transgender issues or may have their own personal biases around transgender folks, which makes a lot of transgender people avoid preventative procedures and preventative appointments such as pap smears or mammograms that can early detect a lot of these issues. But along with this, there’s a lot of issues in like our medical systems and in our insurance coding, where our electronic medical records and our diagnostic tools often fail to be able to like document the nuance that is transgender bodies, right? So this extends far beyond like reproductive health or genitive health and can even include stuff like weight cutoffs for certain medications or the way that organ transplants are prioritized, or even the symptoms of different medical events such as heart attacks. So there is definitely a piece of providers needing to educate themselves around trans issues regarding the, you know, nuance of trans bodies, but also our major systems need to be able to make shifts as well, you know. Such as insurance, you can’t change your gender on your insurance because it won’t cover certain procedures. So say you are a trans man, so someone, a man who has a uterus cannot change your gender marker on your insurance, or else they will not cover your pap series, they will not cover any uterine issues and will create a lot of legwork and refusal to pay.
I hadn’t really thought of that. And that’s a great point is that heart attack symptoms for women and men tend to be slightly different. So when evaluating a transgender person with chest pain or, or symptoms of a heart attack, I’m sure a lot of doctors wouldn’t be aware of that either. What do you think, Rich?
I would agree in the excitement of the moment when you’re in the ER being treated, nobody would think to ask.
Yeah. As a physician, you know, it actually bothers me to hear about so many medical providers having their own bias or against this. I, you know, we all took the hippocratic oath, which is said you know, “do no harm.” So it’s all it’s always concerning to me for physicians to bring some of their own biases into their medical care.
Yeah. Over 20% of transgender people in the United States report being subjected to harsh or abusive language from a healthcare professional and also an almost equal amount say that healthcare providers have blamed them for their own health conditions. Transgender people often report the highest rates of discrimination and barriers to care among the LGBT community.
I forget if we decided whether or not conversion therapy sort of fit into this topic and whether it should be brought up at all. So, what do you think, Micah?
I can definitely provide a quick blurb on that if that would feel helpful. You know, for much of the mainstream me mental health community can, conversion therapy is seen as harmful and now it’s worse is seen as very dangerous. The American Psychiatric Association, as well as almost every mental health association across this country has made statements that conversion therapy otherwise known as reparative therapy, is in fact unethical and is not supported by clinical data to be deemed safe or successful. You know, therapy can be a really useful tool for folks struggling with gender dysphoria, struggling with the stigma around transness or internalized transphobia, but is never meant to be a tool to change someone’s gender or perception of their gender.
I might add that conversion therapy is also considered as a possibility for people for their sexual orientation as well, and it’s just as useless for that.
All the data that shows people who identify as helpful often end up backtracking and saying that it was unhelpful and did not change anything for them.
The attacks against transgender people receiving essential gender affirming healthcare has even extended to hospitals being harassed and healthcare providers receiving death threats from those who believe or willfully perpetuate transphobic lies. The close-mindedness, the bigotry of the people make life harder and more dangerous for transgender people who are just trying to be who they are and live their lives.
The last segment of each episode, we suggest over the culture, art, entertainment, and social causes we’ve been engaged with to each other and our listeners,
I just wanted to shout out a transgender author and advocate. His name is Schuyler Bailar and he goes by the handle PinkMantaray on Instagram and on his website. He runs trans support groups and BIPOC trans support groups, as well as does a lot of education and produces really digestible content for folks around transgender issues and around a lot of these misconceptions and misinformation around trans identities. As well as just want to shout out the ACLU who is doing a lot of work right now to counteract the anti-trans legislation that is happening across the country and doing everything possible to make sure that trans folks maintain access to their gender affirming care and their ability to exist and have happy and healthy lives.
This week I have a podcast, it’s called Outward. It is Slate’s Monthly podcast on queer culture. Hosts Christina Cauterucci, Jules Gill-Peterson (also of the Death Panel Podcast, one of my favorites) and Bryan Lowder have conversations on what sparks pride or provocation, have mind opening conversations with guests, and invite listeners into colorful conversations into the issues animating LGBTQ communities.
Thank you so much for joining us for this episode of Health Savings News, and thank you for Micah for joining us. Please subscribe, rate, and review us on Apple Podcast or wherever you’re listening to the show — it really does help. You can follow @NeedyMeds on Facebook, Instagram, LinkedIn, YouTube, Mastodon, and you can follow @HealthSavingPod on Twitter (for as long as Twitter remains around) for updates specific to this podcast and send questions, comments, and topic suggestions to firstname.lastname@example.org. Our music is composed by Samuel Rulon Miller. His music can be found at musicisadirtyword.bandcamp.com. The Health Savings News podcast is produced by me, Evan O’Connor. All the sources we use in our research can be found in this episode’s podcast description on our website or your podcast of choice. Health Savings News is not intended to substitute professional medical, financial, or legal advice. Always seek the advice of a qualified healthcare professional or appropriate professional with any questions. Views expressed on Health Savings News are solely those of the individual expressing them. Any views expressed do not necessarily represent the views of Health Savings News, other contributors, the NeedyMeds organization or staff. Thanks again for listening. We’ll see you in two weeks with our next episode.