The Hairiness of Trans Health Care
Two weeks ago, mobs of anti-LGBTQ+ Christian protestors descended on the Incheon Pride Festival (South Korea). So, it seems a little unusual that I’ve had a tinge of nostalgia for my transition in this less than hospitable South Korean climate. Perhaps “nostalgia” is the wrong word, “gratitude” might fit my emotional state more appropriately. Though I would never recommend being closeted at work while transitioning — though life often necessitates this choice for some of us — I am grateful for the financial resources it afforded me in my early transition. I was able to pay out of pocket for most of my laser treatments, HRT, and even psych evaluations (Also, Korea equals good deals on dermatology in general. Not only did I get bundles of six sessions of laser for 500 000 KRW [500$US], for a clean million, it also included four sessions of laser to remove those ungainly red ruptured capillaries that white people seem to get in their face [as former Chinese-Canadian boss once said to me, “You white people age so fast!”.)
Earlier this week I received a text from a close friend here in the Netherlands. She had her request for laser denied a third time by her insurer. Ten laser sessions are guaranteed to trans people on Dutch health insurance under the basic care package — which all adults over 18 are required to have. However, the letter of treatment to the insurance company usually comes from the VUmc (the big bad gender clinic), the thing is, my friend is getting health services through another provider. A trans-medicine trained doctor is offering a monthly clinic in Amsterdam through Proud. It’s designed to provide services to the most vulnerable trans people, sex workers and poor immigrants. However, as the wait to see the VUmc for an initial consultation is close to 24 months at the moment, this new clinic is being used by a variety of clients, some young Dutch trans people, some more well-situated immigrants like my friend and I, and also sex workers. While the clinic is very valuable, HRT is prescribed through the clinic and that is a big step, unfortunately, it goes against the grain of Dutch bureaucratic procedure. My friend’s insurance company denied coverage because the doctor at this clinic is not from the VUmc. This denial is mean, unnecessary, probably against the law, but with precedent as most people transition through the VUmc — the vast majority. This denial of services is a big deal, so before I get more into clinical wait times and insurance, let’s explore why my friend needs laser in the first place.
Despite what some would have you believe, that gender/sex comes from essential factors (genitals, gonads, and chromosomes), secondary sexual characteristics, ie. body shape, voice, hair, facial hair, breasts, bone size, etc, are what most of us use to quickly sort strangers into either female or male schema. You don’t look at someone’s genitals or chromosomes to determine their sex (these are also reductionist arguments to disregard trans people based on a simplistic understanding of biology, gender, and sex). Despite this reliance on secondary sex morphology in determining other people’s sex/gender, many people defy these basic morphological categories in some way. For example, I am very tall, but I also have some delicate bone features on my face, a small to nonexistent laryngeal prominence (Adam’s apple), and a slender nose. With HRT and some of these factors in the mix, I can hope to pass (?). Passing is of course problematic, but can provide safety in some contexts. However, one of the most prominent secondary sex characteristics which label people as male to onlookers is facial hair (yes some natal women do have hirsutism [male pattern facial hair]). This is why transitioning dogma states get rid of the beard as soon as possible. This is not only because facial hair is a male associated sex characteristic, but also it’s expensive to get rid of, and it takes a year or more of laser sessions to remove the hair if you are lucky enough to have good contrast between your skin colour and facial hair colour (i.e. lighter skin and darker hair). If you don’t have that contrast, you are probably going to need a lot of electrolysis.
My friend is blessed with very feminine features and an already good response to HRT. However, these positive attributes are at times overshadowed by her facial hair. Beard hair, unfortunately, reads as masculine — someone, maybe Bornstein, pointed out that to read as male is easy, it takes multiple female characteristics to be attributed into the category of female (sexism dictates that masculinity is the default). Facial hair is a large (probably the only) factor which contributes to my friend being misgendered. It is a lot more unusual to see a bearded woman than a tall one. Passing isn’t everything, some trans people are okay, not passing, or wanting a more liminal gender presentation, even while identifying as female. But in my experience, even the toughest of us feel cut, at least a little, when this happens, and when it happens often, well, lots of internal lacerations can kill you. I find being misgendered on the scale of the apocalyptic, for me, it annihilates my sense of confidence in my gender presentation and I suffer it poorly. I cannot say this is the case for my friend, she’s tough, but I know it hurts.
Getting laser is necessary for anyone who wants to be able to pass (no judgment if you don’t want to pass). Unfortunately, living in Europe as a non-white immigrant (my friend), and as a trans femme, reduce ones earning potential. Laser sessions run from around 175–200 Euro each (I needed 16+ sessions), this is no pocket change if you are just scraping by. What this means for people who are not able to pay out of pocket is sustained misgendering, sustained pain, and trauma.
A few days after receiving the third rejection letter from her insurance, my friend called the VUmc to see when they would issue a letter to her insurance. They said the letter would only be issued after she had been prescribed hormones for a year, FROM THEM. Luckily she has seen the VUmc for an initial visit, something I am still waiting for. Keep in mind that my friend has been out as 100% femme for more than a year and on HRT. She needs to wait another six to eight months for a psych evaluation. Some of my friends who have gone through this process say they had up to six of these psych evaluation meetings, all spaced three to six months apart. Only then will they give her a script for HRT and then they expect you to wait a year! This is insane. This highlights one of the central issues with these clinics, they enforce their own temporal clinical sequences on all people, regardless of circumstance. This process would be annoying if you were 16–20 years old. But for my friend and my self, both of us are 32-ish and living every day in our authentic gender, this makes no sense and is negligent bordering on dangerous.
This delay is dangerous because, on this time scale, my friend will be subjected to possibly years more of stress related to being misgendered. There are obvious affective repercussions to this situation: emotional trauma, mental health issues, increased risk of suicide, and of course dysphoria. However, there are also safety and economic factors to consider. This makes her more visible, and therefore open to harassment. Luckily trans femmes aren’t murdered in the Netherlands at the same high rates as other countries, but still, harassment is a real issue. Economically, and this is also an issue for me, being visibly trans equals reduced life chances, i.e. access to jobs, opportunities, education, housing, etc. This, of course, creates less opportunity to pay for the laser out of pocket, thus creating a negative feedback cycle.
It is sad that the clinic has changed so little over the past few decades, even as demands for trans healthcare have exponentially increased with heightened trans visibility. We are still subjected to high gates guarded fiercely by clinical protocols, despite the obvious damage this does to trans lives. I for one am not going to risk my access to treatment when I finally get to the clinic and will lie about my own mental health and gender identity to fit a more normative narrative to receive treatment faster. Of course I’m going to play to the old trope of the high-femme transexual when I go to the clinic, I can’t risk otherwise; I don’t want delays and repeat visits because some clinician doesn’t think I am ready. This also means that my mental health issues have less opportunity to be addressed and treated. The Proud trans clinic in Amsterdam is a much needed alternative system. I know that the doctor applies scrutiny, but ultimately treats adults as beings with agency, thus not delaying their treatment for years unnecessarily. HRT is a big step for many trans people and I am so happy this service is there. But the other medical interventions, the ones that cost thousands of dollars, or tens of thousands of euros, these are still behind gates. I may have had my beard zapped off, but I still need to go through a similar process to get The Operation. And until I do, I will be at odds with my own body and this seriously affects my mental health. The timeframe presented to my friend — and me — rejects our sense of self-determination and unnecessarily puts us at greater risk to a host of factors.
I’m sick of this shit. I’m sick of having to prove myself to cis-designed diagnostic regimes to prove I am trans. There is so little flexibility in this system to adapt to difference, both in gender identity and circumstance. And you know what? Trans people are pretty diverse. The VUmc is bogged down under ever-increasing demand for their services. But their unwillingness to extend autonomy to trans people who clearly have a firm grasp on who they are and what they need is unnecessary and reveals an institutional desire to control the boundaries of gender — who is trans — more than a desire to help people in an expedient manner.
There is an interesting tension between this western model, which is supposed to be progressive and LGBTQ+ friendly, and the Korean model which pathologizes patience to the same degree but treats them quickly. I suspect that both systems focus on conformity to traditional gender categories. In Korea, it is assumed that an adult who goes so far as to seek treatment — which is such a transgression and social taboo — that they are treated as legitimately trans by virtue of even asking. Though this system is not ideal, perhaps its outcome for some trans people is: immediate treatment. In the west, being trans is still seen with much suspicion, maybe it’s just a fad, maybe it’s social contagion, maybe you’re just a gay man, etc. When it is acknowledged, the resulting process is slow and made to ensure that a normative gender narrative unfolds. While these systems are important for some, I can’t help but feel the Korean system better suits two adults who are out, transitioning, and obviously confident in their gender. That said, I’d still prefer the level of tolerance I receive in the Netherlands, but it’s an interesting contrast.