COVID-19 is impacting everything. That includes your trans friend’s surgery.
I don’t normally post content warnings, as I try to make it clear early in my story what I’ll cover so that people can avoid content they don’t want to read. But I’m going to make an exception here: COVID-19 is stressful. Having our medical care delayed is stressful. And reading about this may be more stressful than beneficial. If you’re dealing with possibly delayed surgeries or procedures, I’d suggest something other than continuing reading. This article isn’t for you. It’s for the people who say you’re overreacting.
So, for the person who thinks their friend is overreacting to their surgery being delayed, this is for you.
We know COVID-19 kills people. We know it causes serious illness. We know that keeping as many people alive as possible is a priority. To do this, we need every hospital bed, every nurse, every doctor, every ventilator, and even mundane things like surgical gowns and face masks to be reserved for imminent emergencies.
Our surgeries are life-saving. But they aren’t as immediate as medical procedures to keep someone breathing. If a person doesn’t have air, they might die within a few minutes. Water, a few days. Food, a few weeks. Not having a gender-affirming surgery? We don’t know, but we know that there are consequences for denying trans people medical care. We know that being able to access medical care reduces the chance a trans person might commit suicide, so it is important. While we may have to do things we would never want to do right now, we need to get back to “normal” as soon as possible.
Your friend understands that helping someone breathe is important. They want their relatives, friends, and family (and even themselves) to stay alive.
But, understanding this doesn’t make this any easier.
I’m going to explain one aspect of what may be going on with your friend. I’m going to talk about what they may have gone through to prepare for their gender-affirming surgery, and why it’s devastating when that preparation failed to account for COVID-19.
We move heaven and earth to have our surgeries.
I’m going to talk about the process I went through for one of my gender-affirming surgeries. It’ll be geared more towards trans women than other genders, but I know that trans men and non-binary people go through every bit as much intense preparation and gate-keeping.
I’m writing about my process for gender-affirming surgery. My surgeon, insurance, family, workplace, and mental health providers all had unique requirements, as did my own life circumstances. Thus while I describe my path, no two trans people have the same path. Many have similar paths to me, but many don’t. So please don’t assume anything I write is universal! In addition, the gate-keeping, barriers, and insistence on blending in that the medical establishment force upon us is often unjust and designed not for our well-being, but for the well-being of the gate-keepers themselves. So know that what I write is not an endorsement of that process!
The WPATH (World Professional Association for Transgender Health) Standards of Care for trans people require “full time” real-life experience, typically for at least one year. That means, for at least one year prior to my gender-affirming surgery, I needed to live in my gender — as a woman — whatever that means (when you try to figure out what makes someone “live as a woman” rather than “live as a man,” you’ll discover one of the complaints trans people have with the Standards of Care). The idea is that this gives you a chance to confirm that you are willing and able to handle the bad that comes with being a trans person. As this is a hard rule for many trans surgeries, including what I was wanting, I needed to start that as soon as possible, or I would have to wait that much longer for my surgery.
That meant I started presenting female before my body had caught up with the hormones. I was to use female bathrooms as part of this, even though my body was not much different than that of a typical man. I changed my name and asked people to refer to me using female pronouns while knowing what I looked like while knowing that would attract unwanted attention. And it did.
It also means you have to live like this everywhere. You can’t live as a woman everywhere except work, or everywhere but around your parents. For me, that meant I started living as myself in lower-risk situations first, like around family & friends (who, in my case, were accepting) but waited until I had my presentation reasonably figured out before presenting that way at work. Thus this takes longer than a year for just about everyone.
It wasn’t all horrible — I was happier living as myself, but every time I used a gendered facility or entered a gendered space, I was aware of the incongruence of my body, even if others weren’t aware of it. I felt I had to hide when I was in these spaces. It’s hard to overstate how stressful this can be. And, yes, surgeries can make this easier. I also had the hope that I wouldn’t need to hide quite so much after surgery, which gave me the strength to keep going (that hope was well-founded).
Another requirement for my particular surgery was at least a year on hormone therapy. This has to be planned carefully around real-life experience timelines, as these hormones will cause the person to develop secondary sex characteristics based on the hormones they are taking. For instance, trans men will often develop facial hair and deeper voices, while trans women will develop breasts and undergo fat redistribution. While none of this is predictable, I know for me there came a point where my breast growth would make it much harder to pretend to be a guy!
In addition, shortly before surgery, I had to stop taking my hormones. This meant I went through a forced, immediate medical menopause, similar to a cis-woman who has her ovaries removed. That process is hell. While not every surgeon requires this, some do, and some people may be away from their hormones starting weeks before their scheduled date. Thus, someone who had surgery on April 2nd, but was notified it will be delayed, may have went through this menopause unnecessarily in March. Even after resuming HRT, it will take days or weeks to return to their equilibrium. In the meantime, their mood, heat regulation, and general wellness is impacted by this hormonal roller-coaster. Imagine going through that only to find your surgery was delayed and that all the things you love doing in life have to close down for a few months due to this virus. Certainly, you’re thankful to be otherwise healthy, but the disappointment, particularly combined with the hormonal roller-coaster, is hell.
For some procedures, such as some genital surgery, hair removal is required. This is extremely painful, takes a long time, and needs to be done on a regular schedule to ensure that all hairs are killed (not all hairs are able to be killed at all points in the hair growth cycle, so this can take a year or more). For people who live in places where elective medical procedures like this hair removal are currently delayed, this may allow hair to progress past the point where it can be killed within the current hair growth cycle— meaning it may be another 9–12 months before that hair can be removed, even if the quarantine is lifted in a few weeks. This may push out the surgery another year or more.
Mental Health Evaluation
For some surgeries, mental health evaluations are required. In my case, I needed two of them, completed by people with proper licenses and experience with gender dysphoria. The evaluations needed to indicate I had the proper support system in place for my care before and after surgery, that I didn’t have any other conditions that could be misdiagnosed as gender dysphoria, that I understood what the surgery involved, that I was accepting of possible complications, and that I had met the full-time experience requirements, among other requirements.
The letters written by the mental health providers to document their evaluations are complex and take time (and money) to complete, and sometimes have arbitrary requirements added by insurers or surgeons. For instance, my letters could not be dated earlier than 12 months before my surgical date, rendering one of my initial letters invalid, even though it indicated I met the requirements. Another letter was deemed insufficient because it was written after 11 months of real-life experience. It didn’t matter that I would easily meet the 12-month requirement prior to the actual surgical date, 6 months in the future (after all, if I decided this wasn’t what I wanted and changed my mind, I wouldn’t proceed with surgery!). The requirement was 12 months, and that’s what my insurance required.
Replacing the second letter was easy — it was written by the therapist I was currently seeing. But the first letter was more difficult, as that was written by a different provider who wasn’t currently practicing. That meant I had to find another qualified mental health provider. Fortunately, I have exceptionally decent insurance, so I didn’t need to worry much about the cost of the evaluations, which can run into thousands of dollars. But imagine you don’t have that insurance and you’re living paycheck-to-paycheck. Where does that money come from?
Now imagine the surgery getting delayed — maybe your letter was within the arbitrary validity period for the surgical date, but now it isn’t for the rescheduled one. You’ll have to repeat this process. Depending on whether you still are seeing your mental health providers, this might be relatively easy or it might be a major hurdle that is going to take months while you explain, literally, your life story to new providers.
If you are lucky enough to have medical insurance that covers these procedures, it can take months of arguing to have these procedures pre-approved (and they pretty much always need to be pre-approved). When you pre-approve a procedure, the approval is for a specific time frame. If your surgery is delayed weeks or months, you’ll probably have to obtain pre-approval again.
That’s if you don’t lose your job — and your insurance — because of some virus.
While my experience follows the standard narrative for trans women, my surgery was denied pre-approval three times. I had countless phone calls with insurance, surgeons, mental health providers, and even my GP to get this straightened out. I read way more insurance documents than I ever wanted to read, and I learned all sorts of things about appealing coverage denials. I consider myself to be skilled in dealing with these types of processes and procedures. Even so, three denials took a toll on me. Eventually, I satisfied them that, yes, I had met the requirements from day one.
Of course, I also needed to get time off. In my case, I needed 6–8 weeks off, assuming the surgery went well (there are, of course, no guarantees). I worked out the timing with my management so that my absence wouldn’t cause significant hardship. This meant making sure others could do the work I normally did. I compare this to what an expectant mother might do to ensure a smooth transition while she is out of the office.
Part of this was working out what types of leave I would be using, how I would be paid, and ensuring I had sufficient time off to take care of my medical needs. My work (which then was a different employer than my current one) insisted that, for absences over two weeks, I needed to be on short-term disability. So I needed to go through the pre-approval process with short-term disability. The requirements were generally similar, but slightly different, from the ones I went through with my medical insurance.
I was traveling across the country for my surgery (which is not unusual for gender-affirming surgeries), which meant I needed to live in the area near my surgeon for about 3 weeks following surgery (I’d spend 3 days in the hospital and then the rest of the time in a short-term apartment nearby). During that time, I wouldn’t be allowed to do much. I basically had to remain in bed for most of that time. So I needed a nurse!
Fortunately, my wife was supportive, willing, and able to perform the tasks I needed (none required specialized training, but all required someone other than me to do them). Because my spouse is retired, and we have no children, we didn’t need to negotiate with her employer or a school, but other people may have to do those negotiations and go through the same processes that I had to do with my own work.
People who don’t have family willing to volunteer for these duties may need to hire help or find a friend willing to be with them and take care of them. These people, of course, need to be scheduled in advance, and may not have availability if the schedule changes.
I needed to arrange travel for my wife and myself. Of course, to get a reasonable deal on airline tickets, I booked travel well in advance of my date with non-refundable tickets. Any change to the schedule would, of course, require paying fees and more money to make these changes. Likewise, I had paid the deposit for the short-term apartments, again, which required an advance deposit.
Hospital & Surgeon Scheduling
It’s hard to have surgery without a surgeon or an operating room! Both tend to have tight schedules, particularly for gender-affirming surgeries where the demand exceeds the supply of qualified doctors and facilities. Most surgeons perform several surgeries a week and have dates scheduled a year or more in advance, meaning any change can push you to the end of that line.
They also all want deposits in advance, if any of this is outside of your medical network or if you don’t have insurance. Since there are few surgeons, and the quality of the surgeon is dependent upon the surgeon, I chose an out-of-network surgeon. My surgeon wanted a deposit to secure a date and then wanted full payment a month in advance, while the hospital wanted it a few weeks in advance. I knew that I would probably be reimbursed by insurance after the surgery, but it was still a lot of money. Of course, if the surgery was delayed, the financial burden would likewise be extended.
My surgery was complex, so it was important that I be reasonably healthy. Nobody wants to die on the operating room table! That meant I needed to lose a little weight and pass a few medical tests before my surgery date (all of these tests had to be within a certain amount of time of my date). If my date was delayed, I’d have to continue dieting longer and might find my health changed in the meantime.
Lots of Effort!
All of this added up to a lot of effort.
I lived and breathed surgical preparation for about a year.
Honestly, I’m shocked I was able to maintain other aspects of my life during this time — it is that all-consuming. Somehow, I kept my job and fulfilled my other life responsibilities. Thank goodness there was an end in sight.
Imagine putting in all this effort, all this time, and having that all seemingly ripped away from you. Life as a trans person isn’t easy at the best of times, and we cling to all the hope the world provides.
I’m terrified about what will happen to my trans siblings. As hard as their preparation was, those who will face delays will go through something I can’t imagine going through. I know they are tough. To adapt and adopt Miss Major’s saying, they are still fucking here. But I also know how close I came before my transition to not being here, and I do worry about that a lot in my trans siblings.
So, please, cut your trans friend some slack right now.
To My Trans Siblings Facing Delays
If you ignored my advice and read this essay, please stick around. I won’t say it’s easy, and I do think you’ve been fucked over by the universe. I can’t imagine how awful you must feel. I want you to stick around. Do whatever you need to do to stay alive. Please. We need trans people in the world.