Gender-Affirming Care During the Pandemic

Amid the COVID-19 pandemic many gender-affirming surgeries have been postponed. Seeking gender-affirming care has required our patients to jump through countless insurance hoops, and it takes patients years to get to the point of surgery. This surgery is critical to changing lives. Patients are hurt, disappointed, and struggling for hope in a time when it’s not in abundance.

Gender-affirming surgery is not “elective” in the traditional meaning of the word and should not be labelled as such. These procedures—including facial feminization, laser hair removal, chest contouring, breast augmentation, and genital surgery—can be life and death for our patients. No other surgical population must overcome as many structural and systemic barriers to get to the point of surgery as our transgender populations.

The World Professional Association for Transgender Health (WPATH) guidelines have required therapy, hormonal treatment, and the endorsement of up to two mental health care providers (beyond the surgeon or primary care clinician) that the surgery is necessary. In the best of circumstances, this process can take over a year. And even though many insurance plans are now removing exclusions to gender-affirming care, it remains likely that our patients have to pay for this surgery out-of-pocket due to insurance plan exclusions for medically needed transition-related or “cosmetic” health care (55% of ACA plans).

If at all possible, when “elective” procedures are restricted by local public health officials, or if the coronavirus outbreak is extensive in your or nearby communities and the local situation requires your facility to reallocate resources and reassign personnel to COVID19 duties, please review scheduled gender-affirming procedures to determine those that should go forward based on a holistic consideration of the patient’s physical, psychological, financial, and safety status. Needlessly postponing gender-affirming procedures sends the message that this care is not critically important or necessary when we know it is. It has only been recently that the health professions have begun to make amends for the wrongs  committed to transgender and gender diverse persons—we cannot back-slide during the pandemic.

Know that when you are postponing these procedures to protect your patients from exposure to the coronavirus, you may unintentionally cause mental and emotional distress, and challenge what little hope remains for patients who often have had little reason to hope.

If you must postpone procedures, develop and disseminate your policy on rescheduling. Many of our patients have waited over a year or more to access gender-affirming procedures. They fear they will go to the back of the line in rescheduling. Make your process explicit and let your patients know how it will work. If you do not yet have a policy for how procedures will be scheduled, be transparent in your communication with your patients. The more your patients know, the better.

Avoid platitudes and patronizing language. While we are facing challenges to the healthcare system not experienced in generations, our patients are not naïve to these challenges. Avoid minimizing their own challenges; avoid words like “frustrated,” “inconvenience,” “reasonable,” and “priority.” Transgender and gender-diverse patients have already demonstrated a deep well of patience in the face of numerous, unnecessary challenges to their humanity, as well as their right to access necessary care. Please don’t exacerbate those feelings by being unintentionally patronizing.

Acknowledge the effect of postponing gender-affirming procedures. Know that our patients may experience grief and that their mental health may suffer, and prepare for worsening gender dysphoria for those who experience it already. Apologize for the pain caused by postponing procedures and stress that you do not believe the procedures are “elective” or “cosmetic,” but rather are essential. Our patients need to know we really understand.