Extra parts, extra anger

I have a surgery coming up: a robot, assisted by a surgeon, will be performing a hysterectomy on me in early October. I’m a little squicked out by surgery and didn’t really consider this procedure much before, but my partner’s employer, whose health insurance program I’m on, recently explicitly made trans-related health care costs covered so when my GP offered me a referral to get this done, I thought it made sense.

The day after my consultation with the surgeon, her scheduler called me up and said that she’d double-checked with my insurance and had gotten the go-ahead to schedule the surgery. So easy! But in the weeks following this initial conversation, things have gotten a bit messier.

First, I was told that I’d have to change my health insurance information to say I’m a woman, which struck me a bit odd since this is a specifically trans-inclusive plan and with that in mind they should be all right with guys getting their uteruses out, but whatever. I didn’t really mind making that change and then changing it back after the surgery.
Next, after my partner asked someone about making this change, I got a call from a “patient advocate” at Blue Cross/Blue Shield who told me I wouldn’t have to change the sex on my insurance. Great! But then she started to ask questions related to the medical necessity of the hysterectomy (do you currently menstruate, do you have uterine pain, etc.) and I realized that as it turns out, the approval process was not actually already dealt with despite what I had been led to believe by the surgical scheduler. She wasn’t exactly sure what would need to happen but she got some information for me and promised to call back soon. I was a little confused by the fact that she didn’t seem to know what to tell me, but perhaps I was her first trans client? She is super-helpful but I’ve had a hard time getting concrete answers from anyone so far, which is a little odd.

Also, one of her first questions was “how long have you been transgender?” which… is not really a question I can answer. I think I told her how long I’d been taking testosterone (seven years) and added a year or two to that number? But I do not have any sort of sense of how I should answer that sort of question; it isn’t like that first T shot was the beginning of my identity. But I can’t pin it down to a moment or event, either. My answer is definitely not “my whole life,” and I am very thankful that I have never felt like I had to lie and say this to gain access to care or resources.

A few days later I was given this delightful piece of news: in keeping with WPATH standards for trans-related genital surgery (bafflingly enough, a hysterectomy counts as genital surgery), I would need to provide TWO letters of recommendation from mental health professionals. Two. Letters. I talked to her at length about how gross and condescending that is and she was super-sympathetic and helpful, and did get back to me the next day to say that I now only need one, which I suppose is a tiny victory.

But still, here I am. I am almost thirty years old. I have already had to get Official Approval from a physician and a psychiatrist to start taking testosterone and to have chest reconstruction surgery. At what point am I allowed to sign an informed consent form and make these decisions for myself? Do I really need to go through the demeaning and pointless process of paying a mental health care professional to state my “general identifying characteristics” for the record?

I can do that shit for free, check it out:

  • short
  • glasses
  • messy hair
  • lots of piercings
  • not enough tattoos
  • and sometimes hat

Just for fun, here’s what I was told needed to be addressed in the letter:

  1. The client’s general identifying characteristics;
  2. The initial and evolving gender, sexual and other psychiatric diagnoses;
  3. The duration of the mental health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date;
  4. An explanation that the criteria for surgery have been met, and a brief description of the clinical rationale for supporting the patient’s request for surgery;
  5. A statement about the fact that informed consent has been obtained from the patient;
  6. A statement that the mental health professional is available for coordination of care and wel­comes a phone call to establish this.

I did see a therapist for about a year once I moved here; the stress of the move destroyed a lot of the coping mechanisms I’d developed to handle my depression and anxiety problems and I needed some help with that. But here’s the thing – I didn’t really talk about my gender identity with her. She knows I’m trans and it came up on occasion, but as a way of providing context for other things I discussed, not in any sort of Big Issue way, mostly because I sorted through my Big Issues YEARS AGO, thanks. I haven’t seen her since last fall, but I contacted her and she’s willing write the letter for me. Of course I have to pay for an office visit to get it sorted out, though.

I realize that it looks like I’ll get this squared away without too much personal expense, and that I’m complaining about an aspect of getting this surgery paid for by my insurance when health care coverage is something a lot of people don’t have (especially trans people and/or people in unmarried domestic partnerships). I’m very aware that I’m in a relatively privileged position, here!
But still. Still. I am no stranger to gatekeeping bullshit. I have done this dance before, and even the first time it made me feel like I was being talked down to and disrespected. I should be able to sign an informed consent form without having to pay my former therapist to tell BC/BS about my “sexual diagnoses” (I don’t even think I have any but if I did why the fuck would they matter here?). The list doesn’t even make very much sense to me, to be honest. JUST SKIP TO #5 AND LET ME MAKE MY OWN FUCKING DECISIONS ABOUT MY BODY.

If I had known it would mean this back-and-forth with the company and this pointless therapist visit, I don’t know that I would have tried to schedule the hysto in the first place, or at least not so soon. I’m not sure now why I was so naive as to think that “revolutionary trans-friendly health insurance plan that covers surgeries” would actually mean “we respect you enough not to subject you to demeaning mental health evaluations.” And wow, what a depressing sentence that was to write.

I’m angry. I’m furious, actually. But while I’d love to make a huge fuss and Change the System, instead I’m being surly about it online and going to see my former therapist this week like I’m supposed to. I don’t know how to feel about that. Am I giving in too easily? I’m one step removed from the company I’m insured through, so I can’t really complain to them easily (or without a long process by which point the surgery date would have passed, most likely); at this point I feel like my only choices are to go ahead with this ridiculous letter or cancel the procedure altogether. So on Wednesday I’ll spent an hour talking about how personally offended I am that I have to be at the appointment in the first place, and when I leave I will have this bloody letter and can get on with my life. Bleargh.

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