“A year ago, I was showering in the dark.”
While this experience may seem unfamiliar to some, to many transgender people it’s more than relatable. Turning the lights off can be a simple accommodation when what you see may not match who you are. Chloe, writer of the reflective piece “A Weight Lifted,” thinks back to something as basic as day-to-day hygiene when remembering living before a surgery that changed everything for them.
Though the phrase “top surgery” is used by many members of the trans community to describe various gender-affirming procedures, for Chloe and many others it means a double mastectomy, or removal of the breast tissue, to achieve a flat-chested look. The surgery can be either inpatient or outpatient in nature, and fluid drains, suture maintenance and skin grafts are common features of a recovery process that can take several months.
Washington is a common destination for those seeking top surgery. People who seek breast reduction or removal for gender-affirming purposes may travel across the country — or even internationally — to get operations from popular names such as Dr. E. Antonio Mangubat, Tukwila surgeon of TikTok fame, or Seattle’s Dr. Javad Sajan, whose methods often forgo the infamous fluid drains. However, the cost of the surgery itself — which without insurance ranges in expense from $8,000 to $15,000 out of pocket — prices many out of the procedure. That’s before considering travel and lodging expenses for those who must go long distances to reach their surgeons.
The UCLA Williams Institute estimated in 2019 that “1.4 million adults in the U.S. identify as transgender [0.4 percent of the country’s population at the time], and approximately 152,000 of them are enrolled in Medicaid.” Washington is among 17 states, as well as Washington, D.C., that specifically cover gender-affirming care under this program, and it follows through: Apple Health paid for Chloe’s top surgery.
“The surgery was a dream. Everyone’s good vibes, the ancestors, it all was working. And my surgery was free-95, free-thank-you-Obama!” Chloe said.
The weight lifted off of Chloe’s chest means a similar relief for more Medicaid recipients seeking top surgery.
“I kept asking, ‘Are you sure [it’s free]? Like, this doesn’t sound right.’ I was in denial up until the day of — I’m still in denial. I’m still waiting for a check to be sent!” they said.
The state regulation that addresses gender-affirming care comes with a hefty load of stipulations. In addition to presenting a diagnosis of gender dysphoria, the patient must present a letter from a psychosocial clinician confirming the diagnosis to authorize the procedure. Fortunately, both reductive and additive top surgeries don’t have the mandatory second evaluation and 12-month hormone therapy requirement other procedures do. However, the cost and accessibility of psychological confirmation can still present hefty barriers for Medicaid recipients. Accessing top surgery through Medicaid is a much longer process than filling out a simple form. It can be hard enough for transgender people to find a therapist who affirms something so personal, let alone one affordable enough.
Working in the medical system
Chloe struggled to access the existent gender-affirming care offered by another medical corporation. They were informed that there weren’t specialists or support systems for their gender-affirming care when they contacted the health insurance provider on the phone. Only upon asking other trans people did Chloe discover that both of these programs existed and still exist today.
“I’d never felt so invalidated, like such an other,” they said of their difficulty finding trans health care at Kaiser. “I thought surgery would be the hard part, but it was living with the gender dysphoria.”
Gender dysphoria can feel like a disconnect between how one experiences their gender versus how they feel perceived, or like having a personal incompatibility with one’s body. Gender dysphoria is often highlighted in authorization papers and is a guiding factor toward qualifying for trans health care under Medicaid.
The onset and persistence of the COVID-19 pandemic has made it more difficult to set surgery dates. In addition to medical short-staffing and the complete overwhelming of hospital systems, effects of long-haul COVID and hospital outbreaks lend more uncertainty toward procedures that are currently considered optional.
Top surgery is often misunderstood as an elective procedure — “nonessential,” a term given extra heft by the pandemic crisis. As the pandemic settled in, top surgeries were put on hold, leaving patients in the lurch with an uncertain procedure time frame, sometimes after years of planning and preparing. The effect of this misclassification is tremendous on those seeking affirmative surgery and how trans health care is perceived as a whole.
Luckily, Chloe’s surgeon was on the ball.
“When Jay Inslee reinstated the rule against elective surgery… the plastic surgery office sent me a message saying this could be a lifesaving surgery,” they said.
Recovery from top surgery is slow. It often starts with drains, rounds of painkillers and the occasional difficulty doing everyday things like using the bathroom. It graduates into limited arm movement, skin graft “reveals,” removal of day-long binding and giddy smiles at a flatter figure. The swelling reduces and the arms’ reaches extend, but it takes months before one can lift their arms above their head again.
Aftercare support isn’t covered by Medicaid: from gauze and Aquaphor to mobility aids and physical therapy, ensuring a steady recovery comes out of one’s own pocket, outside of managing follow-up appointments that can stretch several weeks apart.
“I just didn’t realize how much bandages, medical tape, Neosporin and how all that adds up. ...The shelf [at the Bartell’s] is always empty every week,” Chloe said about their out-of-pocket aftercare. While surgery itself is free through Medicaid — which reduces the bulk of the cost for many who are insured under the program — it still may not be enough. To take the last step, trans people turn to each other.
An essential surgery
What is classified as a “cosmetic” procedure is, for some people, nothing short of a life preserver. Day-to-day physical improvements post-operation include the foregoing of wearing a binder, a piece of clothing that resembles an undershirt but constricts the chest in order to bind breast tissue to achieve a flatter look. When worn for long periods (according to many manufacturers, as little as eight hours) or improperly, binders can cause discomfort, trouble breathing and even fractured ribs. People gain a fuller range of motion when they don’t wear binding clothing. The discomfort from sweat and friction is relieved; belting a favorite line in a song gets that much easier with more lung capacity.
Emotionally, the relief is immense. Many conversations with trans people about gender revolve around dysphoria, but it’s time to add nuance to the conversation. There is also gender euphoria, which is the self-realizing feeling that comes from experiencing one’s own gender in a way that opposes feelings of dysphoria. Some people find euphoria in their gender experiences without experiencing dysphoria, which doesn’t make them any less trans. Trans-affirmative health legislation must create avenues for those whose identities are informed by indicators of joy instead of alienation and discomfort.
Now that they have gotten top surgery, Chloe lives this euphoria daily. Dating is more accessible. Swimming holes in the summer invite instead of taunt. This essential surgery, similarly informed by dysphoria and euphoria, continues to improve lives and is offered on Medicaid.
“This summer is the whole vibe,” Chloe, a swimmer, said. “Tits out, 2022!”
W. Barnett Marcus is a contributing writer for Real Change.
Read more of the Jun 22-28, 2022 issue.