In January 2020, I was feeling hopeful. I’d just had a long-awaited gender-affirming surgery to masculinize my chest, and fantasized about hitting the beach topless and showing off my results at Pride. Unfortunately, my body had other plans—I struggled for two months with unforeseen healing complications and had to schedule a revision surgery to help smooth out the uneven areas of my chest and clean up the thick, uncomfortable scarring I’d developed. Then, COVID-19 hit the West Coast—medical care in Portland screeched to a total standstill and I could only speak to my plastic surgeon through email and video calls.
“I want you to be happy with your chest,” she told me, “but we’re not scheduling any surgeries and I have no idea when we’ll be able to get you in.”
I’m finally recovering from that second surgery—more than a year and a half later. Between my surgeon’s backlog of desperate patients, medical staff shortages, and convincing Medicaid that a second surgery was, in fact, medically necessary and not simply “cosmetic,” it took six months just to get a date on the books. As the date approached in July, the world had seemed to be approaching something resembling “normal” when the delta variant appeared in Oregon, and hospitals around the state began running out of hospital beds. My hospital announced halfway through the month that they were delaying and canceling some elective procedures, and would reach out to affected patients. I spent the two weeks before my surgery date glued to my phone, waiting for the call. It’s impossible to describe the level of anxiety that comes with living in that kind of limbo. I’m still surprised my surgery proceeded as planned, with a smooth recovery and none of the complications I encountered last time.
Many of my friends have not been so lucky. For weeks, my social media feeds were filled with desperate people whose surgeries have been canceled and don’t know when they can expect to be rescheduled. One friend keeps receiving messages that their initial surgical consult is being moved back; another was told it would probably be a year or two before they could even set an appointment with a surgeon to discuss the procedure. Unfortunately, with the appearance of the delta variant and vaccination rates still lagging, it’s unclear when or if the situation will improve.
Major medical organizations in the U.S. agree that gender-affirming care is essential care, including the American Academy of Child and Adolescent Psychiatry, the American Medical Association, the American Psychiatric Association, and many more. Study after study has shown that access to transition care dramatically improves quality of life for trans patients, resulting in a decrease in psychological distress, a reduction in suicidal thoughts, and lower rates of smoking and substance abuse. The isolation of the pandemic combined with the medical delays hit the trans community especially hard—people are suffering under the strain COVID-19 is putting on our healthcare system and how it’s exacerbating preexisting barriers to trans health care.
Accessing gender-affirming surgery is already a struggle
Gender-affirming surgeries weren’t the only elective procedures affected by the pandemic, but trans patients are in an entirely different situation than cisgender patients. Accessing gender-affirming surgery was already a long, uncertain, and anxiety-inducing process even before the pandemic. Most doctors and insurance plans require a gender dysphoria diagnosis and at least one letter from a therapist before you can even be referred to a surgeon. Some surgeons have lengthy wait lists, particularly those who work with low-income communities. And trans patients often spend years saving up for their surgery, which can cost thousands of dollars out of pocket even if their insurance plan covers the procedure—for many, the cost is simply an insurmountable barrier. After struggling for so long to schedule a surgery date, having it canceled or delayed at the last minute feels like a slap in the face after so much effort.
Additionally, while elective plastic surgeries were delayed last year by about eight weeks on average due to COVID-19, these figures don’t take into account the number of people who may have simply given up due to financial concerns. Even before the pandemic, trans people already suffered disproportionately from unemployment and poverty due to widespread workplace discrimination–one study published in February 2020 found that trans people were 11% less likely to be unemployed than the general population, despite being only 1% of the survey sample, with a full third of the trans respondents living at the poverty level.
This divide only widened during the pandemic, particularly for transgender people of color. A Human Rights Campaign report found that 58% of BIPOC trans people in the U.S. had their work hours reduced last year due to COVID-19, and 26% became unemployed–dramatically higher numbers than the general population. A staggering 67% reported concern that they wouldn’t be able to pay their bills. Even as surgeons work through their waitlists, the reality is that many people simply don’t have the financial stability to access care at all.
Why gender-affirming surgery is so important
It’s easy to think that an “elective” surgery is optional. But that’s simply not the case. Many medically necessary surgeries are considered elective when a patient is not in immediate danger without an operation. Issues requiring elective surgery like hernia repair, knee replacement, and even some heart surgeries have all been delayed due to the pandemic. None of these procedures are an emergency, but not having them can prolong a patient’s pain or allow their condition to worsen over time. Many experts have expressed concern that classifying elective surgeries as “non-essential” causes disproportionate suffering for women, LGBTQ+ people, and people with chronic illnesses.
In the case of gender-affirming surgery, the issue extends far beyond changing one’s outward appearance. Living every day in a body that feels fundamentally wrong taxes a person’s mental health and medical delays and additional barriers because of the pandemic has only made that toll worse. The Trans Lifeline reported an 89% increase in calls related to suicidal ideation last summer, and calls from people distressed that they couldn’t access medical care doubled.
And in many cases, surgery is necessary to interact with the world safely. In some states, surgery is required to update one’s gender on identity documents–a barrier that can put trans people at risk of violence and even impact our ability to vote or open a bank account. Everyone has their own reasons for seeking surgery. Not all trans people want or need it, but for many it can be life changing.
No easy solutions exist to address surgical delays
Unfortunately, there are no easy answers to solve this problem. With some hospitals running out of beds and others facing staff shortages, it’s not feasible for many doctors to press ahead with non-emergency surgeries or schedule new procedures. The additional refusal of some healthcare workers to get vaccinated is not only exacerbating staffing issues, but in states where vaccine mandates are illegal, they’re also putting vulnerable surgical patients at an additional risk of infection.
Some doctors are trying to address the problem by advocating for a more nuanced approach than hospitals took last year, when PPE and ventilators were almost impossible to come by. Many hospitals are evaluating elective surgeries on a case-by-case basis before canceling or delaying them. Some healthcare workers are even arguing for creating a new, tiered system to categorize procedures based on urgency, rather than whether they’re considered elective. However, it’s not clear exactly what the criteria for these systems are and where gender-affirming procedures might stand.
It’s easy to argue that a patient with cardiac problems needs surgery sooner rather than later to avoid complications down the line. Doctors can point to a patient suffering from chronic back pain and argue that they need to be treated to maintain their quality of life. But it’s so much harder to quantify psychological pain, and trans patients are such a small minority–with only 16,000 gender-affirming surgeries carried out in the U.S. last year–that our needs might end up being overlooked entirely as hospitals attempt to triage. Additionally, systemic transphobia is a pervasive problem in the U.S.: The 2015 US Transgender Survey found that 55% of respondents were denied insurance coverage for gender-affirming surgeries in the past year, and that 33% reported negative experiences with healthcare providers, ranging from verbal harassment to refusal of service. Trans care is already consistently devalued in the medical field, and the pandemic exacerbates those existing pressures.
Sadly, there seem to be no organized efforts on the national or state levels to ensure that transgender patients are able to receive consistent access to care during this crisis. Healthcare workers and policymakers have been stretched to the breaking point trying to address the pandemic itself—with so many competing priorities, trans care is an afterthought. And the LGBTQ+ rights groups that might normally champion the cause have been forced to spend their time and resources fighting a flood of anti-trans legislation, some of which is aimed at gradually eroding access to gender-affirming care entirely. When trans people are constantly forced to fight for our very right to bodily autonomy and the freedom to exist in public, it leaves few resources for other battles.
For now, it seems, the most that can be done is ensuring that the trans community has the resources and support needed to cope with the uncertainty of a difficult situation. Organizations like The Trans Lifeline, The Trevor Project, and the LGBT National Hotline provide peer support for people in crisis. Allies wanting to help should consider donating to these organizations, or finding local resources in their community they can support. These can be LGBTQ+-specific, but the truth is that simply volunteering at a food pantry or a shelter helps too–while not everyone using these services is trans, trans people are much more likely to rely on these services than their cisgender peers.
Perhaps one of the most effective interventions of all? Doing your part to help control the pandemic. It’s impossible to solve the systemic barriers to quality trans healthcare through individual action, but by wearing masks, avoiding crowded gatherings and high-risk activities, and getting vaccinated, we can each do our part to help ease the burden on our hospital system so that everyone can get the medical care they need. Encouraging those around us to help stop the spread of COVID-19 benefits us all.