On the Challenge of Trans Medicine
What does it mean when I say I am the Director of Trans Services?
The title is not an accident. I am not the Director of Trans Medicine — that title belongs to a medical provider, which I am not.But I am the administrative head of the department, and there is a question that I am in the process of asking myself right now, and that question is what does that mean?
What are the Services?
Some of the things I am interested in doing I am limited by licensing or legal issues or related elements that get in the way of simply doing my damndest to make sure that trans people are taken care of.
I would love to set up a housing program, for example — and if you are even vaguely familiar with me you can likely guess that I can establish a metric ton of reasons for that to have a medical basis and be of import. I can do that without even really trying, and since I would try, it would shatter a lot of preconceptions (and perhaps when I turn my attention to some governmental issues, I will address exactly that).
But loving to do so and actually finding a path through the hell that would be involved in doing it through a large company are two things so disparate, that I am not sure it will ever happen.
Meanwhile, I suggest it, and even offer to help those in the area to do so (because, well, you gotta raise a shit ton of money, and you can’t do this kind of work and make a profit), and instead I get to hear how I am a horrible person doing terrible things and I am like “um, ok,”
One of the things that is important to me is that we do “whole health” — that is, we are not just here to do your hormones and refer you for surgeries and write the damn letters that I hate and have a dedicated and ongoing campaign against the rationales for.
Trans people need cervical exams, need mammograms, need colorectal exams, need stuff that is super useful and really valuable to one’s life *beyond* once we take care of those basic things. End of Life stuff and palliative care — how well does your local Hospice system or systems deal with Trans folk?
We have a well developed and successful system for things like pregnancy — I am stunned at how effective our care there can be. But, like in many places, it is very maternally oriented, and trans masculine side folks — trans men and nonbinary people — need something that addresses their needs more acutely and recognizes those needs. We are doing it, right now, and there is little resistance beyond challenges that would be common to any large org.
And then there is the rest of the stuff. I had originally wanted to open up a surgical center when I laid out the ten year plan, but that was in year seven. I may still get to do it (but things change, so maybe not) but in any case, it would require a whole different licensing structure. And it wouldn’t be for bottom or similar complex surgeries.
But what I can do is leverage existing opportunities to build that capacity using partnerships with local hospitals. That would give us the ability to reduce travel time and improve overall outcomes.
Next up is the process of documenting results and ensuring that recovery happens. This will enable us to help start a process for effecting change with surgeons — and enable tracking of overall complications by surgeon.
The downside is that if we are tracking, surgeons might not want to sign up with medicaid insurance providers because then they would be tracked. Given how hard it is to get a surgeon to sign up and *stay on* right now, I cannot be entirely happy with them overall.
The next thing is that I can start to look at the stuff I am finding myself neck deep in — the way that insurance works.
Flat out, that fucking sucks. As an example:
An individual opts to pay out of pocket with a given surgeon and is quoted a price in the five figure range.
Then insurance is able to cover the same procedure, and the deductible is way less. Like, mid three figures.
However, surgeon does not have an existing agreement with the insurance company.
Insurance company goes to surgeon to find out how much to do these procedures. Surgeon gives them a price in the six figure range. Literally 30 times higher than what the surgeon told the Individual.
Insurance company balks at this, because insurance company knows the out of pocket price.
Insurance company comes back and tells surgeon they can pay this much, about eight times the original out of pocket price.
Surgeon contacts the Individual and says that they will take the insurance payment, but the patient needs to cough up the out of pocket price as well.
This is a real thing. This happened. I am so used to hating insurance companies that I wasn’t ready to face the serious bullshit of how all of this is done.
When you talk tot he providers, they talk about hospital costs and equipment costs and all these other factors that sound totally reasonable.
Right up until they are charging a completely different, way lower price from someone who does not involve insurance.
Even if I had not been in favor of a nationalized health care system before now, I would be utterly in favor of it after that.
And that is just direct, surgeon to insurance. Hospitals are way worse about that, and the way they can contract for 100,000 and get paid 25,000 and call it even is something that strikes me as outright fraud.
I have a very, very different view of the whole thing around health care. Hell, before we even get to a nationalized health care system, I think we should implement price controls. This is how much that given surgery costs, and it will cost that much no matter where in the US one is.
And for Trans folks, that is especially important since insurance coverage is still “new”. Insurance companies still haven’t figured out how to write the damn coverage plans.
Let alone get surgeons into network. I mean, seriously, I tried for a full year to get surgeons into a network for an employer based plan, and was turned down over and over again.
By the surgeons. Before they even talked to the insurance companies.
While there are a lot more now than there were a decade ago, and a lot of them are offering the stuff that a lot of us want, they are still thinking in terms of the old stuff, the old way, the “suffer and be abused until you save up enough from your minimum wage job and your side work sex work hustle to pay for our stuff”.
That one company that charges almost usury rates? Nope. Put yourself in hock for the rest of your life is not an insurance plan for health care.
And besides, we worked our assess off to make that coverage in the ACA happen, regardless of some fucking racist misogynist, transphobic, dishonorable little shit in Texas.
Naw, I want there to be some solid ways beyond word of mouth, ways that allow us to identify improvements to care. I want there to be standards.
So I will find a way to do that.
It definitely means that I will want to do research, and mine data and find ways of showing how successful we are and get folks to be willing to update the damned protocols for HRT for the first time in a few decades.
Especially the whole thing about the entirety of our treatments being “off label”. There should be more research and data showing and demonstrating risks as they apply to trans people.
Not just “well, we guess this is the case based on the stuff we found out with these men or these women.”
What are the heart attack symptoms for trans people? How often do trans people develop liver or kidney issues? What is the proper dosage for estrogen in its different forms?
I can *see* all of this. The potential, the possibility — and sit with me long enough and I can make you see it as well. But only if you want to see it.
A lot of folks don’t. Not usually because they don’t like trans people or anything but because this shit is not easy — it is hard. It is fucking hard. IT is frustrating and mind numbingly slow and there is no recognition or tangible reward and so a lot of folks just fucking give up.
Burnout for me comes after too many people asking for too much of my time at once — but I gotta say, being able to work from home has been a huge blessing for me.
First year here I put 30,000 miles on a brand new car. I literally killed the engine. Because I never stopped. It was a miracle that I got it covered under warranty.
(also, well, you know, girl thing)
Of course, it was just me, then. Today there is an amazing team to share in the frustration.
I am not someone who gives up, though. It isn’t in my DNA. I can accept a loss, I can handle a setback (or a series of them), but what I can’t handle is giving up or quitting.
That hurts me.
It is so ingrained, that I had to be certain within myself before I started transition. I had to know this was what I was going to deal with, and it didn’t matter what I was going ot face, and I didn’t need some sort of special DNA or chromosomal or carefully figured out series of questions…
I just needed to know if this was what was in me, within me, part of me.
IT was. But I wasn’t going to start only to quit if it got hard. ANd fuckin A, it was hard. SO fucking hard. I mean, yeah, I thought about killing myself, but that was because my son was being taken away. And I didn’t. Because I couldn’t find my shoes.
But I didn’t try after I was raped. I didn’t stop or change my mind or anything. Being homeless didn’t change any of that. The increase in racism didn’t do it. The constant misogyny and the attacks of all the terfs and even the glass left on my door step didn’t do it.
I do not give up. I didn’t give up so much as have to turn to being a caregiver and sucked the life out of me several years ago, and yeah, I have to admit that I did lose the ability to give a shit and I honestly waited to die of a broken heart.
But I didn’t.
Instead, I just kept going. Beause that is what I do. Give me a mountain to climb and I will climb it.
And maybe that is the real meaning of trans services.
TO be in service. TO climb that fucking mountain so that the path up can be lit and illuminated.
OF course, knowing me, once I do I will go back down and start again, helping those who need it climb on up…