LOS ANGELES — Jyn Dao is scared. His bottom surgery — needed to realign the female genitalia he was born with to his male identity — is scheduled. But it’s not happening until January. And like many trans men and women, he’s afraid President Trump will soon revoke protections in federal law that ensure his surgery is affordable.
“Me, my friends, people in the trans community, we’re really worried,” said Dao, a 25-year-old Vietnamese-American who has been slowly transitioning his gender over the past decade.
If insurance coverage disappears, he added, “a lot of people are going to be trapped in their bodies — including me.”
Republicans in Congress have not been able to overturn the Affordable Care Act — at least, not yet. But the Trump administration is working to revise a section of the law that says federally funded health programs cannot discriminate on the basis of sex.
The Obama administration made clear that this provision required states to cover transgender care through their Medicaid programs. Now, however, Health and Human Services Secretary Tom Price has told a federal court that he’s reworking the rule and won’t enforce it in the meantime.
Already, some states have defied the Obama directive and specifically excluded transgender care from their Medicaid coverage. And Wisconsin, Texas, Kentucky, Kansas, and Nebraska are teaming up with Christian health care providers to challenge the anti-discrimination rule in federal court. (It’s in response to this case that Price filed the motion in May indicating that he is revising the regulation.)
Price’s stated goal: to strike down rules that cause “regulatory or economic burdens.” The administration already has made it clear that it views transgender surgeries as a heavy burden; in July, Trump cited the cost of that care as a primary reason for barring transgender people from serving in the military.
The rewrite now underway could free states to refuse to cover hormones, counseling, and surgery for transgender men and women.
“I’ve fielded a number of calls from members asking if they’re going to lose their benefits,” said Emmi Monsour, a health plan case manager here who specializes in helping trans members navigate the tricky insurance landscape. “Their anxiety is at a fever pitch.”
And so, she said, many members want to get their surgeries scheduled right away. That’s rarely possible. Surgeons are scarce and wait lists stretch for years. Said Monsour: “We have members right now scheduled for surgery — in 2019.”
“I’ve fielded a number of calls from members asking if they’re going to lose their benefits. Their anxiety is at a fever pitch.”
Emmi Monsour, health plan case manager
Providers, too, see progress slipping away.
“I thought we were making great strides,” said Dr. Johanna Olson-Kennedy, medical director of the Center for Transyouth Health and Development at Children’s Hospital in Los Angeles.
Her patients and their parents are not only anxious about their medical coverage, she said, but also about a palpable uptick in hostility and violence following Trump’s public actions to undercut protections of trans rights
“It’s really disappointing to go backwards,” she said.
Trouble finding care, even in L.A.
Even in a progressive city like Los Angeles, where LGBTQ health centers dot the landscape and the annual LA Pride march attracts tens of thousands, it’s difficult to get access to gender reassignment (sometimes called gender confirmation) surgeries. They include “top surgeries” — specialized mastectomies to remove breast tissue and reduce nipple size — and “bottom surgeries” to restructure the genitals. Such procedures cost $10,000 to $20,000.
For years, the surgeries were rarely covered by insurance, and even if they were, there was often so much confusion and paperwork that many gave up or paid out of pocket if they had the means. Some sought cheaper surgeries in Mexico or Thailand, often with horrifying results that sent patients back to U.S. doctors in need of complex surgical revisions.
“If you think doing a vaginoplasty in normal conditions is hard, try fixing one after a botched surgery done 20 years ago,” Mansour said.
Even in the U.S., results can be spotty. Dao, for example, needed a revision of his first mastectomy. The surgeon had removed breast tissue, but not enough. His nipples were uneven and scarred. Dao, an avid athlete and championship badminton player, was reported for using the men’s locker room at his college when someone saw his bare chest.
“I lost all my confidence,” he said.
But Dao considers himself fortunate because he was able to get both his original surgery and the revision covered by his insurance. He’s a member of L.A. Care, the nation’s largest publicly operated health plan, which insures more than 2 million low-income residents of Los Angeles County. His previous plan, he said, offered little help when he called asking about transition services. “They had no idea what I was talking about,” he said. “They kept transferring me to different people.”
By contrast, the care of trans patients is such a priority for L.A. Care that it employs case managers just to help them. L.A. Care’s Trans Health Care Management program is led by Hieu Nguyen, an openly gay licensed clinical social worker who runs initiatives in behavioral health services. Trans health is closely linked to mental health, he said, because many trans members suffer from depression and anxiety related to gender dysphoria, the dissociation they feel between their assigned gender and the gender they identify with.
“Our mission is to work with vulnerable populations,” Nguyen said from a 15th-floor cubicle at the plan’s office, which overlooks not only the gleaming, new 73-story Intercontinental Hotel, but also a large homeless encampment along the 110 freeway snaking through downtown.
“If you’re talking about the most vulnerable, it’s our trans members — economically, socially, physically and emotionally,” he said.
Trans health care began to improve in 2014, Nguyen said, when some states used the Affordable Care Act to expand Medicaid to cover low-income childless adults — a population that he estimates includes thousands of trans patients in California alone.
California is among 12 states, along with the District of Columbia, that have written clarifying rules reinforcing the Obama-era guidelines that Medicaid must cover transition-related care. California’s Department of Insurance conducted an economic analysis that found the cost of transition services was minimal.
Even so, until recently, few low-income people were succeeding in getting trans surgeries paid for, Nguyen said. “There was no clear process; people were getting inappropriately denied. Even LGBT-focused providers didn’t understand the process for to accessing care for patients,” he added. There was misunderstanding of rules by both insurance plans and providers.
And of course, there was discrimination.
“I had a client from another program whose doctor said, ‘Why do you want to be a freak?’” Nguyen said.
“A lot of people are going to be trapped in their bodies — including me.”
Jyn Dao, transgender patient awaiting surgery
Such experiences nudged L.A. Care leaders to find a way to make things easier for trans members. While a majority of case management is contracted out, trans health is handled in-house — by Monsour, with oversight from Nguyen. Program outreach includes booths at public events like LA Pride, complete with handout rainbow flags emblazoned with the L.A. Care logo.
Nguyen and Monsour spend a lot of time recruiting providers who will accept Medi-Cal, the California version of Medicaid. To make sure the doctors are compassionate, they call patients from the trans community to suss out how well they’re treated by both the physicians and their front office staff.
“We do the Hieu and Emmi cultural competency test,” Nguyen said. “There’s no standards right now, so we do our due diligence.”
It seems to be working. L.A. Care is becoming known on trans message boards as a health plan that provides access to qualified surgeons for medically necessary gender surgeries. Since 2015, 40 members have successfully undergone surgeries and some 240 are in the pipeline, Mansour said.
And now many are rushing to schedule procedures before the anticipated crackdown from the Trump administration.
That’s not an easy process. Before they qualify for surgery, trans patients must get a referral from a primary care doctor and up to two letters from a licensed mental health professional who has assessed their readiness. In some cases, they first need to undertake a year of hormone therapy.
Mansour, who spends much of her day on a headset speaking to plan members, is busy. She stepped away from her desk for a short time recently and returned to find seven voicemails waiting.
Mansour, who is trans, is hopeful California’s safety net will continue to provide trans medical care regardless of what happens at the federal level, but she can’t be sure. The uncertainty saddens her.
“Members have been told ‘no’ for so long, then one ray of light comes down,” she said. “And now they think it’s going to all be taken away.”
She can’t even imagine what people in less progressive parts of the country are going through.
A hard-won self confidence
Dao is looking resolutely forward.
He’s come a long way from the 11-year-old who emigrated from Vietnam with only four words of English. The college graduate now tosses around complex medical terms like metoidioplasty and periareolar nipple reduction with the ease of a surgeon and is extremely comfortable discussing his life and decisions.
But for years, Dao had struggled. In high school, he was confused. He really liked girls but he didn’t like being one. He didn’t think he was a lesbian, but didn’t know what to call himself. He cut his waist-length black hair shorter and shorter each year and started secretly posting online glamorous shots of himself dressed in his older brother’s clothes. He quickly developed a large female following.
His parents, however, were horrified once they found out. His mother, who works in a nail salon, kept telling him to get cured. (Vietnamese culture, he said, is starting to be more accepting of gay men but not of lesbian women and people who are trans.) Therapy did nothing to dissuade Dao. He just kept things hidden.
When hormone treatments started to deepen his voice, his mom asked if he was sick. But there was one thing he couldn’t hide: He hadn’t had a period for a year. “The mom knows,” Dao said.
“I thought we were making great strides. It’s really disappointing to go backwards.”
Dr. Johanna Olson-Kennedy
By this point, after years, his parents were starting to come around. They welcomed his friends, and girlfriends, into their home.
Handsome and self-confident, Dao works out, takes protein powder in hopes of building muscle, and uses testosterone shots as well as testosterone facial cream to maintain his facial hair.
Dao is working as a behavioral therapist with kids with autism but is considering a career change. He recently tried the Los Angeles Police Department’s academy but dropped out with a serious knee injury. He’s thinking about pilot school or jobs in business. And he soon plans to propose to his long-term girlfriend.
He’s hopeful that his metoidioplasty — a procedure to enlarge his clitoris into a small, male-like organ that should allow him to urinate while standing — will go forward no matter what changes the Trump administration makes, because it’s been approved by his insurer and scheduled.
But he’s not taking any chances — and took the first surgery slot he could. “Trump does not support the transgender community,” Dao said. “That’s why I was in such a rush.”