Navigating Transitions

By David J Everly / Winter 2020

All throughout my life I struggled against social injustice in the medical system. It began when I was about 12 years old. At that time, I would have greatly benefited from what are known as hormone blockers in order to bypass the freight train of female puberty. However, in order to obtain these hormone blockers, I would have needed over a year of therapy, signed documented letters from a psychiatrist and a mental healthcare provider who were working in tandem on my case, and over 3 years of continuous care and what is known as “counseling” by a primary physician; all of which I did not have. As a result of not having any of these things, as well as signed documents from my parents allowing the doctors to initiate hormone blockers, I suffered for an additional 7 years through every phase of female puberty. In that time, I experienced an innumerable amount of my days in the deepest points of grief, dysphoria, frustration, horror, bewilderment, and even sought my own death on more than one occasion.

I can vividly remember the first time I sought out mental health treatment through Kaiser, my family’s HMO. I explained to the provider that I had never felt like I belonged in my body and had felt male since my earliest recollections. Naturally, the first thing I would hope and expect a good medical care provider who is being paid to offer up the best possible medical education and advice to a concerned family and their child to tell that family and their child about the term “transgender” and about the potential treatments. Instead of doing this, I was brought into a room alone with the provider and asked questions like “when did you have your last period” and “when was the last time you were sexually active,” which, at that point and not until after my physical transition, had I ever been. I would later find that the core reason behind not getting information from this provider was the fact that this provider and others did not have access to recent literature and still saw gender dysphoria as, primarily, a mental illness rather than a health condition. This comes down to a problem that still arises in our medical communities, namely health disparities associated with discrimination, lack of education on part of the clinicians, and unequal treatment of patients based simply on who their provider is. It’s quite likely that had I simply found a provider that was more proficient in the latest literature concerning my condition and who had no discrimination involved in people with gender dysphoria, I would have been treated much sooner.

In light of these events, a continuous question I’ve had to ask throughout my life is why is something as fundamental and imperative as the need for quality medical care reduced to things like discrimination and social inequality and why are the disparities so staggering in a country that has such a large pool of resources? In terms of my topic, I am left feeling greatly saddened and hopeless because our group of individuals is even smaller and easier to overlook that the general population, especially under the current administration. Over the course of the last 4 years, the Trump administration has sought to greenlight sex discrimination under the guise of religious liberty. A series of policies that target our access to healthcare, workplaces, schools, and other spaces are currently in the process of being passed across the United States. Furthermore, and possibly most damaging of all, one section of their briefing filed with the Supreme Court just last year mentions specifically that sex stereotyping is not by itself a Title VII violation. This, in other words, means that Trump and his administration and lawyers are arguing that this section of the Civil Rights Act that prohibits employers and doctors from discriminating because of sex does not prohibit them from discriminating on the basis of the stereotypes related to it. In particular, HB 1057, recently passed in South Dakota, bars transgender youth and their parents from making decisions about their medical care, and allows the state to arrest and imprison any doctor who provides that care for transgender or gender non-conforming youth. This piece of legislation is one of several bills that has been introduced under the Trump administration that directly targets the transgender community (Puckett, 2017). There are many who support these laws because of a fundamental belief that doctors are performing irreversible surgeries on children without parental consent or before the child has the ability to discern whether or not this is truly the best decision. However, it is extremely uncommon for transgender teenagers in general to undergo gender affirming surgery because most medical professions advise waiting until adulthood and because the process of obtaining such surgeries is so lengthy. This bill is more likely to affect teenagers who, like I was, are seeking puberty blockers or injections that keep them from experiencing harmful levels of dysphoria during puberty. Medical professionals who treat transgender youth advocate that these medicines could be lifesaving, helping to diminish the anxiety and depression and suicidal behavior that is rampant amongst transgender youth going through such events. For many of us, the development of our bodies during puberty is like being hit by a freight train and causes such deep psychological trauma that even after treatment is given in adulthood, PTSD symptoms and deep trauma remains that often lasts for years or a lifetime. It wouldn’t surprise if the states that have passed and will pass these laws in the future experience an increase in the suicide rates among transgender and gender non-conforming youth, but the chilling aspect of this is that it is likely this is the news nobody will read about or hear. The majority of those that commit suicide in their youth, are subjected to discriminatory medical treatment, and are murdered for being openly trans are going to be African American transwomen; another fact you will not hear about or read in the news. This is a deep multifaceted problem that needs to be remedied, but can only be remedied if we are recognized and seen by the public as human beings and not legislative decisions and statistics that are quickly tossed under the rug as another youth dies or experiences the severe trauma associated with not receiving the life-saving treatments that medical professionals have to offer.

The deeper story behind this problem is multifaceted. It lies in the fact that, as a nation, we have succumb to centuries of discrimination and viewing entire races, classes, and genders as inferior. As Lorber mentions in her writing, gender has become so much a familiar part of daily life that it actually takes a deliberate disruption of its norms to get everyday people to recognize how it is produced. It is more comfortable for society, in general, to put boys in the “male” category and girls into the “female” category. When faced with a transgender individual, the response is almost always social dislocation and discomfort. Gender construction is even trickier on these grounds. Gender construction, as Lorber mentions, often begins with the gender we are assigned to at birth based on the way genitalia look. This is taken a step further today by powerful groups like the Trump administration and its supporters who pass laws to police a binary that has been defined by sex characteristics that can be seen and are not necessarily inherent to the individual behind those characteristics. This, however, is problematic in and of itself for those struggling with intersex conditions and those who are transgender. They feel, as I did, that we never got the opportunity to choose, but that our gender was chosen for us to our own detriment. This is all based on gender construction. Although gender is based on genitalia at birth, and gender rules are enforced by clothing and names and pronouns from the time a child is only a few days old, as soon as a trans or intersex child can talk they often report telling their parents exactly what gender they are. In my case I was very explicit about telling my father that I would grow up to be a policeman or a fireman from the age of 3, and many other’s in similar positions can attest to this same phenomenon. Although gendering is done from birth, gender cannot be equated with biological and physiological differences between human females and males because blocks of gender are socially constructed statuses. Many other cultures in the past have made room for third genders, as the “manly hearted women” of African and American Indian societies or the berdaches and hijras of other cultures who are treated as women although they were born male. Our Western society is different insomuch that it lacks this third category and transgender people are given no room to assess their gender, but rather are quite forcefully lumped into one of two categories. Genders, nevertheless, are breachable boundaries; signaled to us biologically by the fact that intersex conditions exist from birth, signaled to us culturally by their existence from ancient times, and signaled to us individually whenever a 3 year old explains to her father that she is going to, indeed, be a policeman rather than a policewoman. The deeper story behind the problem can only be solved by our Western culture as a whole diving deep into the reasons behind these ideologies about gender and beginning to see things from a broader point of view.

In our world, there are currently many roadblocks and health disparities that block the way for essential resources to be given to trans patients (Safer, 2016). On March 23, 2010, the Obama administration passed the ACA. In one moment, everything that trans patients had dreamed of having access to in terms of surgery and medical care was given to them. On March 30, 2010, I began my hormone replacement therapy while still covered under my parents’ insurance and, because of the ACA, eventually was given the option to stay on that plan until I was 26 years of age. This would prove to be a saving grace for me, as aspects of my surgeries such as phalloplasty and the implantation of an erectile device cost upwards of 100,000 dollars. Had it not been for my father’s governmental health insurance with its amazing coverage, it is likely that I would have never obtained all of the surgeries I needed to become whole as a trans man.  Fast forward 10 years and it seems we are 20 years behind in the way of transgender medical care, research, and coverage. From the moment the Trump administration has had the opportunity, it has sought to roll back transgender medical rights in insidious manners, such as the laws that were passed in South Dakota barring medical doctors from caring for transgender patients and the limitations it sought to put onto the ACA. For example, many insurance companies could and would see my condition and the condition of every other transgender patient who has undergone surgery as a pre-existing condition. Under the previous clause of the Obama administration, all such pre-existing conditions were covered and insurance companies could not discriminate on coverage based on such factors. However, Trumps administration immediately targeted aspects of the ACA such as the pre-existing condition clause and the ability for children to stay on their parents’ plan until 26; two of the exact clauses within the ACA that allowed many trans youth like myself to obtain life-saving surgeries and continue to have coverage outside of their parents plan regardless of any amount of liability they then posed to insurance companies as post op trans patients.

Ultimately, it is the fault of the ideology that gender is assigned rather than something inherent to the individual that is our main obstacle as a group. This social stigma that rests on the head of every non-binary and transgender person continues to exist because of a culture that has perpetuated an ideology based on fear of stepping outside of that gender norm and not truth (truth is never black and white). The shades of gray in this story are those who fall between the cracks of the black and white male and female genders that our society allows for and instead compose the third gender that can be so many different things. Potential allies to the cause of those who fall between the cracks and land in this third place of gender are prevented from joining in solidarity due to gender constructs being so comfortable and normal in our society. As a transgender man who passes well, I experience these same rules on a daily basis. Because of the way I present, the world around me now expects me to act a certain way and hold certain values as a young man. Whenever I mix up the norm and choose not to hold those values or act certain ways I disturb the dominant ideology around me regarding gender and my place in it, but I also allow others to free themselves as well. This needs to happen on a wider scale. Until our society as a whole begins to view gender and sexuality as a spectrum rather than black and white extremes that we are bound to, it will be very difficult to overcome the obstacles we face as a group.

When I think of the principles that can help us overcome the obstacles that I’ve outlined in the preceding pages of this paper, the only words that come to mind are that of MLK in his excerpt on Chaos and Community in “The World House.” In it, he goes to great lengths to express how racism, xenophobia, and poverty are issues that cannot be resolved by simple fixes because all of these things are based on multifaceted complex foundations that have bases in ideologies and belief systems that enormous groups of people have embraced, some knowingly and some simply by default. In one part that deeply spoke to me, he explains that nothing is new about poverty in and of itself; rather, what is new is that we now have the resources to get rid of it. He goes on to express with great passion and insight how he cannot understand why there can be hunger and privation in our land or any land if man has the resources and scientific understanding to provide the necessities to fix the issue. In further pages, he expresses that what we are dealing with are ancient habits, vast structures of power, and very complicated problems that are driven by fear, and that the only way out of this current situation is by preparing to undergo mental and spiritual re-evaluations which will enable us to see the things we currently can’t and generate a readiness to change our focus from black and white to gray, so to speak. It is precisely these principles that King outlines in his speech, principles that include solidarity, courage, empathy and deep re-evaluations, that I believe will be necessary if we are to overcome the obstacles facing us, not only as a small group of transgender individuals seeking a few medical rights, but as a nation and a world. I’ve been in King’s place and wondered for long periods of time why, in a country with so many resources, the care of the marginalized is diminished. When we could put an end to the suffering of so many, why are we still caught up on bathroom laws and whether or not to allow transgender patients to transition in some states? As far back as you can go into ancient civilizations, the third gender was there Whether or not it was recognized was based on those in power, but it always existed just as poverty has always existed. I think back to what it may have been like to have been transgender under Roman rule or another political power that obviously left no room for a third gender and before any surgeries were made possible by medicine and I know I would have had an excruciatingly painful life. The difference today is that we actually have the resources to eliminate that suffering. When a physician takes the Hippocratic Oath, they promise to remember that they do not treat a fever chart or a growth of cancer but, rather, a human being who is sick and needs their care and to respect all secrets confided in them; binding them in essence to a higher law than the law of the land but, rather, a medical law. It is not fitting for physicians today who swear by such a law to refuse treatment to those who are sick and suffering and in need of care. As much as a physician promises in that oath not to simply treat a growth of cancer or a fever chart, it should also follow that they do not treat a “trans” patient, a “black” patient, or an impoverished patient, but simply a patient who comes to them with symptoms that they have been given medical answers for. When we can shift the norm, through the ethical principles I have outlined, to physicians beginning to treat patients rather than diseases, then I believe we will be closer. This will need to be implemented through strategies that the ACA already sought to implement and the Trump administration has rolled back. Incentives will need to be given to physicians for quality of care vs quantity of care and legislation will need to be passed that opens up the door to patient centered care rather than care based on income. Underneath all of this change, however, is that core belief that MLK emphasized which was a call for neighborly concern beyond one’s race or class or tribe and simply an all embracing and unconditional love for all men. Whether the issue is poverty, racism, xenophobia, or LGBT and transgender rights, the message is the same and the guiding principles of empathy, solidarity, and dignity are still lighting our path.

In light of all these things, it is only fitting to conclude on a set of principles that we can use to create a more democratized medical system that gets communities the resources they need and also integrates the marginalized into positions of power. In order to do this, I can truly only draw from my experience. In the darkest moments of my journey I reminded myself that regardless of the fact that there seemed to be glaring contradictions at play within this system I was navigating, only I was in control of how I responded to those contradictions. It would have been immensely easy for me to give up during the course of the six years that I spent waiting for the medical system to wake up and realize that I was in desperate need of surgeries such as hysterectomy to be covered to prevent endometriosis. After I got my hysterectomy, it would have been equally easy for me to respond in a negative way to the fact that I still needed to wait for the medical system to cover phalloplasty on the basis that they refused to see it as necessary for us as patients and, rather, as a cosmetic choice. A group of individuals within our community and I petitioned Kaiser to include these surgeries for years. We began in 2009 until 2010, two years after I had received hormone replacement therapy and was unable to receive hysterectomy because it was still seen as “cosmetic” rather than medically necessary. We went to court hearings and were present at the time when the ACA began Covered California. We also petitioned Kaiser for these years, called numerous offices of physicians and other groups in charge of our care and sat on hold for hours. We contacted different physicians all over the state of California both involved with Kaiser and outside of it and sought to find ways to get a transgender educational system in place in order for trans patients to have more doctors available that understood the transgender care plan and in order for an actual care plan to exist at all. Though the process was long and tedious, changes eventually were made. For many years, Kaiser did not wish to cover surgeries for transgender patients, but eventually was overcome by legislation passed by the state of California and, in accordance with this, created individualized care plans for every transgender patient navigating the surgical route and organized its own specific care teams. Although Kaiser is now seen as one of the most excellent and sought-after providers for transgender care with a transgender center in Los Angeles and a complex transgender care plan and care team that all exists within the medical HMO, it was not always such and took great work on behalf of the initial patients involved in the process to push for such change. Though relatively small in scale, I believe that this is a prime example for how ethics can be translated to action on a larger scale; namely, through continuous persistent action and the organization of communities of people that care with communities of people who may not have the information available as to how to create the change they have the power to create. It was through this slow, unrelenting process that my friends and I witnessed the change many others now enjoy through Kaiser. In order to face the groups that I’ve spoken of in previous pages that are passing anti trans laws as I write this, it will take this same slow, unrelenting process of community building and organization to combat the dominant ideologies of those who oppose us and, ultimately, that same process will be called upon to create the future we know we should have; a democratized medical system that serves the needs of communities in need rather than the needs of a capitalist system.

My story is not unlike that of many others who have come up against strong forces when trying to initiate change. As my friends and I grow older, we all realize the importance of the role we now play in our society, based on the same responsibility that King talks about when he references neighborly concern and unconditional love for all men. My goal to become a medical doctor who advocates for the rights of people who are struggling to get the treatments they need is only part of that story. I know that if I am to practice medicine, I will surely encounter all kinds of patients. I will encounter trans patients and gender non-conforming patients as well as Trump supporting patients and patients who hold rigid conservative religious views that, should I expose myself as trans, would vilify me to them indefinitely. Overall, transgender individual experience unique health disparities but are the subject of little focused health research (Feldman, 2016). This is why my goal to obtain an MD/PhD is so important, because research and care providers who have an inside understanding are so essential and so lacking. Should I become one, my goal as a medical doctor will be to treat every patient I encounter with the same unconditional love and respect that I know is necessary to facilitate the shift in thinking that will lead to real lasting change for marginalized groups like mine. It is imperative that we experience this shift if we wish to see a better world in the future that offers communities the resources they need while also integrating the marginalized communities into positions of power in order to significantly alter the curve of what we are experiencing as those who struggle with discrimination. Though I could go on for pages about administrative changes I could make and laws I could seek to overturn, I still believe the most powerful way I can initiate the change I feel is necessary is through my own example of the love King describes. I do not have a picture in my mind of a “utopia” where all marginalized communities get the best possible medical care and all transgender patients are seen as quickly as possible and with the same compassion regardless of the provider. However, what I do have with me because of my journey are the tools I think will be necessary to get to a place close to this. The greatest of these is love. As King expressed in his last paragraph of his speech on “The World House,” the oceans of history have ever rising tides of hate that make them uneasy and turbulent. But, nevertheless, love is the ultimate force that unites us, makes the saving choice of life and good above death and evil easier to make, and that love will have the last word should always be the first hope of our inventory. As he remarks so passionately in his final plea for humanity, we are now faced with the fact that tomorrow is today, that the urgency is now, and that, though procrastination is the thief of this time that we have to facilitate change, we still have a choice today to make those changes that will impact the futures many others experience tomorrow. This is the truth that I kept in mind every moment that I navigated my own perilous journey through the medical system as a transgender man, and this is the truth that I believe will bring ethics to action and spur the change we need for a brighter tomorrow. All of the choices we make today are going to impact the future that we realize tomorrow, and all of the people we encounter will also similarly impact that future; in ways that may be big or small. What is necessary from us is only our mindset about what the future can be and the ability to bring the proper tools to the table as we address it. If we fix our minds on any tool in our inventories that does not contain hope, love will not have the last word.

Works Cited

Feldman, Jamie et al. “Priorities for transgender medical and healthcare research.” Current opinion in endocrinology, diabetes, and obesity vol. 23,2 (2016): 180-7. doi:10.1097/MED.0000000000000231

Puckett, Jae A., et al. “Barriers to Gender-Affirming Care for Transgender and Gender Nonconforming Individuals.” Sexuality Research and Social Policy, vol. 15, no. 1, 2017, pp. 48–59., doi:10.1007/s13178-017-0295-8.

Safer, Joshua D et al. “Barriers to healthcare for transgender individuals.” Current opinion in endocrinology, diabetes, and obesity vol. 23,2 (2016): 168-71. doi:10.1097/MED.0000000000000227